Please enable JavaScript in your browser to complete this form. - Step 1 of 3In accordance with MANDATORY State Guidelines for Pools during Phase 2, all patrons must complete this form prior to entering the facility ON THE DAY of EACH use of the facility. This form must be completed by an adult over age 18. If a minor child will be using the facilities without an accompanying adult (such as for swim practice or lap swimming), a parent or guardian must complete this form on behalf of the minor. Anyone experiencing COVID-19 symptoms will not be permitted entry to the pool.Person Completing Form *FirstLastEnter the name of the person completing this formReservation Time *Select one...9:30 AM (Swim Team)10:45 AM (Swim Team)11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PMWhat time is your reservation?Members *Select one...12345678How many in your household are using the HRARA facilities today?Enter the name(s) of all household members visiting today.Member 1 *Member 2 *Member 3 *Member 4 *Member 5 *Member 6 *Member 7 *Member 8 *NextAre you currently experiencing any of these symptoms?Check below to indicate whether you - or a family member planning to use HRARA facilities today - are currently experiencing any of these symptoms, or have experienced these symptoms within the last 24 hours - that cannot be attributed to another health condition or specific activity (such as physical exercise).I/we are experiencing *Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheLoss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrheaNo symptomsPreviousNextHave you been exposed to COVID-19?Have you had close contact with anyone who is known to be positive for COVID-19 within the last 14 days, even if that person is asymptomatic?I/we have been exposed *YesNoDo you understand and accept the state guidelines and facility rules?I understand that if I am experiencing any of the symptoms of COVID-19, or have had contact with anyone known to be positive for COVID-19, that state guidelines and facility rules prohibit me from using the facility today. By completing this document and using the facility today I attest that I have answered this form truthfully and to the best of my knowledge.I/we accept the rule *YesNoSign and SubmitYou have reach the end of the screening. Please sign your name below and press the "Submit" button.Signature *Clear SignaturePreviousPhoneSubmit 2020-06-16
