Health Screening Questionnaire
Please complete the following form. In order to maintain a safe environment for our teachers and students during in studio practice we must ask you to provide this health screening information.
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First & Last Name *
Today's Date: *
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Have you been fully vaccinated against Covid-19? If yes (optional) please provide the dates of each shot below. You may qualify to attend in person maskless classes. Email us for more information - infourbanyoga@gmail.com
Cell Phone Number *
Email Address *
Have you Traveled out of the United States of America or to a known COVID-19 hotspot or come in contact with an individual infected by Covid-19 within the past 14 days? * *
If yes, Where?
Have you had any of these symptoms in the last 14 days? *
If you selected any of above listed symptoms as positive, it is our right to protect the health and safety of our teachers and students and we ask that you not to enter the studio at this time. We welcome you to join us at another time. Please type your full name below to acknowledge that the information you provided is accurate and timely *
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