Student Health Screening Questionnaire
In accordance with the CDC regulations, Pal-O-Mine Equestrian is being mandated to follow the new recommendations and procedures to reduce the risk of exposure from COVID-19. Please complete and electronically sign this screening questionnaire and submit prior to coming onto the property. E-mail riskassessment@pal-omine.org if you have any questions/concerns. This must be done prior to EVERY visit to Pal-O-Mine. Your participation is mandatory in helping us take precautionary measures needed to protect you and everyone in this setting.

Email address *
What is your name?
Select all that apply for your visit today: *
Required
MOBILE/HOME PHONE NUMBER
MAILING ADDRESS
I agree to indemnify, defend, and hold harmless the Released Parties from and against any and all costs, expenses, damages, claims, lawsuits, judgements, loses, and or liabilities (including attorney fees) arising either directly or indirectly from or related to all claims made by or against any of the Released Parties due to bodily injury, death, loss of use, monetary loss, or any other injury from or related to my use of the Pal-O-Mine facilities, tools, equipment, individuals, or materials, whether caused by the negligence of the Released Parties or otherwise specifically related to COVID-19. *
Have you tested positive for COVID-19 within the past 14 days? *
Have you or household family members had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? *
Have you or household family members experienced any cold or flu-like symptoms in the last 14 days (fever, cough, sore throat, respiratory illness, difficulty breathing)? *
Have you or anyone else in your household travelled outside of New York State in the last 14 days? *
SIGNATURE *
DATE *
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YYYY
A copy of your responses will be emailed to the address you provided.
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