COVID-19 QUESTIONNAIRE 2020-2021

X-CEL ATHLETICS CHEER AND TUMBLE ACADEMY LLC, HOME OF STEP 1 ALLSTARS NORTH

Please keep in mind that the following questions are pertaining to your athlete that will be attending the facility at 8505 Mulberry Rd. Chesterland, OH 44026

First Name*

Last Name*

Email*

Phone*

HAVE YOU OR YOUR CHILD BEEN IN A COVID-19 HOT SPOT AS STATED BY THE LOCAL GOVERNMENT IN THE LAST 14 DAYS?*

Yes
No

DO YOU OR YOUR ATHLETE LIVE WITH SOMEONE THAT CURRENTLY HAS COVID-19?*

Yes
No

DO YOU OR YOUR ATHLETE LIVE WITH SOMEONE THAT HAS HAD COVID-19 IN THE LAST 14 DAYS?*

Yes
No

HAVE YOU OR YOUR ATHLETE TRAVELED OUTSIDE THE UNITED STATES IN THE LAST 14 DAYS?*

Yes
No

HAVE YOU OR YOUR CHILD BEEN DIAGNOSED WITH COVID-19 IN THE PAST 14 DAYS?*

Yes
No

If you answered yes to any of these questions, please do not participate in gym activates for 14 days. Adherence to the 14 days self-quarantine is extremely important to the health of all other individuals. If your status changes, you must notify us immediately. Lack of doing so, may end in suspension from the program.

Consent*

I HAVE READ THE COVID-19 QUESTIONNAIRE 2020-2021 AND UNDERSTAND THAT IF AT ANYTIME, I CAN ANSWER YES TO THE ABOVE QUESTIONS, I MUST NOTIFY X-CEL ATHLETICS AT 440-824-0300 OF THE CHANGES. I UNDERSTAND THAT MY ATHLETE WILL NOT BE ABLE TO PARTICIPATE IN PRACTICE/CLASSES FOR 14 DAYS. I ALSO UNDERSTAND THAT NO REFUND WILL BE GIVEN. I UNDERSTAND THAT IF I FALSIFY ANY OF THE QUESTIONS, I CAN BE HELD LIABLE FOR FALSIFICATION DOCUMENTS AND WILL BE SUSPENDED FROM THE PROGRAM.

Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.

COVID-19 QUESTIONNAIRE 2020-2021

X-CEL ATHLETICS CHEER AND TUMBLE ACADEMY LLC, HOME OF STEP 1 ALLSTARS NORTH

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