Staff Health Form | Thompsons Gymnastics

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200 Old Lyman Rd.

South Hadley, MA 01075

p: 413-532-0374

e:

Covid-19 Health Declaration

How are you feeling today?

Staff Form

First Name

Last Name

Work Time

Email

I do not have a fever

Myself nor anyone in our household has any symptoms of Covid-19

I have not been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

I declare that the info I’ve provided is accurate & complete

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Thompsons Gymnastics Center

200 Old Lyman Rd. South Hadley, MA 01075

413-532-0374

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