Long Island Aikikai COVID19 Waiver and Acknowledgement of Responsibility Form
Student First Name *
Student Last Name *
Please answer either Yes or No to the following statements *
Yes
No
I have tested positive for Covid19 and have since tested negative and/or quarantined myself for at least 14 days.
I have tested positive for Covid19 Antibodies and currently have no symptoms.
I have tested negative for Covid19 and/or Covid19 antibodies.
I have not been tested for Covid19 and/or Covid19 antibodies.
I have health conditions that put me at a higher risk for severe reactions and/or death due to Covid19.
I live with or come into regular contact with anyone who is at a higher risk for severe reactions and/or death due to Covid19.
What health conditions do you have that put you at a higher risk for severe reactions and/or death due to Covid19? *
Please confirm your understanding and acceptance of the following statements by checking on their corresponding box. *
Required
Long Island Aikikai COVID19 Waiver and Acknowledgement of Responsibility Form Executed by: *
If you are over 18 years of age, please enter your name below. If you are under 18 years of age, the parent or legal guardian that has completed this form must enter their name.
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