CLIENT COVID-19 RESTRICTIONS AND DECLARATION FORM

CLIENT: COVID-19 DECLARATION

Personal Details
Client Name*

First NameLast Name
Phone number*
Mobile number
Client E-Mail*
Exclusions and restrictions to training
Are you currently required to be in quarantine because you have been diagnosed with COVID-19?*

YesNo
Have you been directed to a period of 14 day quarantine by the Department of Health and Human Services (DHHS) as a result of being a close contact of someone with COVID-19?*

YesNo
If you answered YES to either of the above questions you should not leave your house until advised by the DHHS that you are released from quarantine or until your 14-day quarantine period is complete.
If you answered NO to the above questions, proceed to the symptom checklist below.
Are you experiencing any of these symptoms?
- Fever/chills
- Sore throat
- Runny nose
- Cough
- Shortness of breath
- Loss sense of smell or taste
- Headache
- Stuffy nose
- Vomiting or diarrhoea
I am experiencing the symptoms listed above*

YesNo
If you answered YES to any of the above questions you should not attend your session (or you should leave if already there). Tell your trainer, go home, and get tested for coronavirus (COVID-19). If you answered NO to all the above questions, you can attend your session. If you develop symptoms, stay at home and seek further advice from the 24-hour coronavirushotline 1800 675 398 or your general practitioner.
Please read and agree to the following:
1. If I have been in contact with a confirmed case of COVID-19, I must not attend face-to-face sessions until further medical advice has been given.
2. If I start to feel unwell or experience COVID-19 related symptoms during my session, I will inform my trainer immediately and we will cease training. The trainer also has the right to send you home if they believe you are showing cold/flu like symptoms.
3. I will not attend any sessions while awaiting the results of a COVID-19 test, or if I have tested positive.
4. If I test positive to COVID-19, or if I have been in close contact with a confirmed case, I must inform Fitness Keeper (if you have been in contact with us within 14 days).
5. I will abide by hygiene and social distancing measures, including:
- I will not arrive more than 5 min prior to my session. If I am running early I will wait in my car or in another area (if I have not driven) until my trainer is ready to train me and is no longer with the client(s) who may have trained before me.
- Using hand sanitizer (provided, or my own) prior to and at the end of each session.
- Keeping at least 2m apart from my trainer (and any other client) throughout the session.
- Coughing/sneezing into the arm. If using tissues, disposing of them safely and sanitizing hands after use.
- I will only use equipment that I bring myself, or that has been disinfected & provided to me for my sole use within my session.
- Masks are not required to be worn if exercising outdoors with social distancing. Masks should still be carried when leaving home unless you have a lawful reason not to.
- After my session I will not congregate and will leave my session in a timely matter.
I confirm I have read, understood, and will comply with the above terms.*

YES
Confirmation and declaration
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

CLIENT: COVID-19 DECLARATION

Exclusions and restrictions to training

If you answered YES to either of the above questions you should not leave your house until advised by the DHHS that you are released from quarantine or until your 14-day quarantine period is complete.

If you answered NO to the above questions, proceed to the symptom checklist below.

Are you experiencing any of these symptoms?

Please read and agree to the following:

Confirmation and declaration