Fitler Club COVID-19 Health Declaration Form

The safety of our employees, members, guests, and vendor partners remains Fitler Club's main priority. And the best way to prevent illness is to avoid being exposed to the virus. Therefore, we are requiring you to complete this questionnaire in order to protect you and everyone who enters Fitler Club. Thank you for your time.
Date: 08/05/2020
  1. During the past 14 days I have not tested positive or presumptively positive with COVID-19 or been identified as a potential carrier of the COVID-19 virus.
  2. During the past 14 days, I have not experienced any cold or flu-like symptoms that are not due to a known, non-worsening chronic condition (e.g. fever** or chills; cough; shortness of breath or difficulty breathing; fatigue; muscle or body aches; headache; new loss of taste or smell; sore throat; congestion or runny nose; nausea or vomiting; or diarrhea).
  3. During the past 14 days, neither I nor anyone within my household knowingly has had close contact with a person who has COVID-19, a cold or flu-like symptoms.
  4. During the past 14 days, members of my household and I have practiced social distancing in accordance with the guidelines of the Centers for Disease Control and Prevention (“CDC”).
  5. I agree to promptly notify the management office of the Fitler Club if I discover that any of the declarations set forth in paragraphs 1 through 4 above were inaccurate in any material respect at the time I made such declarations, or if any of my responses to paragraphs 1 through 4 above are no longer accurate based upon a change in circumstances.
  6. When I am in the Fitler Club’s facility, I agree to comply with the Fitler Club’s rules and regulations regarding social distancing, the wearing of a face cover, remembering to cover my mouth and nose with a tissue when I cough or sneeze, or to use the inside of my elbow, throw used tissues in the trash and immediately wash my hands with soap and water for at least 20 seconds, or if soap and water are not readily available, clean my hands with a hand sanitizer that contains at least 60% alcohol.
  7. I consent to having my temperature taken when I enter the Fitler Club’s facility.
  8. I understand that this questionnaire is intended to be used for virus spread prevention purposes only and is not designed to replace the care or advice of a medical provider.
  9. I hereby release, waive, discharge and covenant not to sue the Fitler Club and/or its respective affiliates, parents, subsidiaries, owners, directors, officers, employees, representatives, successors and assigns (the “Released Parties”) from any and all claims, loss, damage, causes of action or liability they may incur arising out of my exposure to infectious diseases, whether or not the same arises out of or results from any act, omission, negligence or conduct of any of the Released Parties. I specifically agree not to sue the Released Parties in connection with exposure to COVID-19 for any reason whatsoever and HEREBY AGREE TO INDEMNIFY, SAVE AND HOLD HARMLESS THE RELEASED PARTIES FROM ANY LOSS, LIABILITY, DAMAGE, OR COST INCLUDING BODILY INJURY, ILLNESS OR PROPERTY DAMAGE they may incur arising out or related to my being exposed or diagnosed with COVID-19.

*A member that cannot provide this declaration will not be permitted access to Fitler Club’s facility without further consideration. 

**According to the CDC, a temperature of 100.4º is a fever. In Philadelphia, a temperature of 99.8º is a fever. 

Because of the recent increase in COVID-19 cases in numerous states across the United States, the Health Department has issued the following recommendations:

  1. People should not travel from Philadelphia to any of the red states below if it can be avoided.
  2. People traveling to Philadelphia from any of the red states below or from international travel should self-quarantine for 14 days. If self-quarantine is not practical, they should for 14 days after traveling to Philadelphia:
    • Wear masks at all times at the workplace or near other non-household members, and
    • Monitor closely for the development of new onset of cough, fever, or other COVID-19 symptoms; if these symptoms occur, follow our guidance for isolation (PDF) and get tested for COVID-19.

Red states include: Alabama, Arizona, Arkansas, California, Florida, Georgia, Idaho, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah