ECE & Youth Health Check Questionnaire

Please enter today’s date *//

What is your email *

What is your child's first and last name? *

First

Last

What is your child's temperature? Please round to the nearest whole number. *

Please select the program your child is enrolled in *

ECE
YOUTH

Do you have another child attending an ECE or Youth Summer Program at the J? *

What is your next child's first and last name? *

First

Last

What is your next child's temperature? Please round to the nearest whole number. *

Please select the program your child is enrolled in. *

ECE
YOUTH

In the past 24 hours, has anyone in your household experienced any of the following symptoms: cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, headache, sore throat, loss of taste or smell, diarrhea, feeling feverish or measured temperature greater than or equal to 100.0 degrees Fahrenheit. *

Has anyone in your household recently been in contact with anyone who has exhibited any of the previously mentioned symptoms? *

Have you recently (preceding 14 days) been in close contact with anyone who has lab confirmed positive for COVID-19? *

Have you, or anyone in your immediate family, recently traveled to a restricted area that is under a Level 2, 3, or 4 Travel Advisory according to the U.S. State Department? Including China, Italy, Iran and most countries in Europe? *

Please list the temperatures of all adults living in your home.

Parent/Guardian Name *

First

Last

Waiver, Release, Indemnification of All Claims & Covenant Not to Sue NOTICE: THIS IS A LEGALLY BINDING AGREEMENT: Read this document carefully and in its entirety. By signing this agreement, you give up your right to bring a court action to recover compensation or obtain any other remedy for any personal injury or property damage, however, caused, arising out of or relating to your entry onto the premises of the ALPERT JEWISH COMMUNITY CENTER located 3801 Willow Ave. Long Beach CA, 90815 (“the ALPERT JEWISH COMMUNITY CENTER premises”) or your participation in any program or activity taking place anywhere upon the ALPERT JEWISH COMMUNITY CENTER premises. Acknowledgment of Risk: I hereby acknowledge and agree that participation in activities upon the ALPERT JEWISH COMMUNITY CENTER premises comes with inherent risks. I have full knowledge and understanding of the inherent risks associated with such participation, including but in no way limited to (1) slips, trips, and falls, (2) aquatic injuries, (3) athletic injuries, and (4) illness, including exposure to and infection with viruses or bacteria. I further acknowledge that the preceding list is not inclusive of all possible risks associated with such participation and that said list in no way limits the operation of this Agreement. Coronavirus / COVID-19 Warning & Disclaimer: Coronavirus a/k/a COVID-19 is an extremely contagious virus that spreads easily through person-to-person or other contact. Federal and state authorities recommend social distancing as a means to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in programs or activities upon the ALPERT JEWISH COMMUNITY CENTER premises could increase the risk of contracting COVID-19. The ALPERT JEWISH COMMUNITY CENTER in no way warrants that COVID-19 infection will not occur through participation in programs or activities upon the ALPERT JEWISH COMMUNITY CENTER premises. Waiver, Release, Indemnification & Covenant Not to Sue In consideration of my being permitted to enter upon the ALPERT JEWISH COMMUNITY CENTER premises: I, the undersigned participant, agree to release and on behalf of myself, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE the ALPERT JEWISH COMMUNITY CENTER, its officers, directors, employees, volunteers, agents, representatives and insurers (“Releasees”) from any and all causes of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I, my heirs, representatives, executors, administrators and assigns may have, now or in the future, against the ALPERT JEWISH COMMUNITY CENTER on account of personal injury, property damage, death or accident of any kind, arising out of or in any way related to my entry upon ALPERT JEWISH COMMUNITY CENTER premises, the use of any of the ALPERT JEWISH COMMUNITY CENTER facilities or equipment, and my participation in any of the ALPERT JEWISH COMMUNITY CENTER programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to the negligence of Releasees. In consideration of my entry upon the ALPERT JEWISH COMMUNITY CENTER premises, the use of any of the ALPERT JEWISH COMMUNITY CENTER facilities or equipment, and/or my participation in any of the ALPERT JEWISH COMMUNITY CENTER programs, I, the undersigned participant, agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, or costs of any nature whatsoever arising out of or in any way related to my entry upon the ALPERT JEWISH COMMUNITY CENTER premises, the use of any of the ALPERT JEWISH COMMUNITY CENTER facilities or equipment, and/or my participation in any of the ALPERT JEWISH COMMUNITY CENTER programs. I hereby certify that I have full knowledge of the nature and extent of the risks inherent in my entry upon the ALPERT JEWISH COMMUNITY CENTER premises, the use of any of the ALPERT JEWISH COMMUNITY CENTER facilities or equipment, and my participation in any of the ALPERT JEWISH COMMUNITY CENTER programs and that I am voluntarily assuming said risks. I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, or death, I sustain as a result of my entry upon the ALPERT JEWISH COMMUNITY CENTER premises, the use of any of the ALPERT JEWISH COMMUNITY CENTER facilities or equipment, and/or my participation in any of the ALPERT JEWISH COMMUNITY CENTER programs and that by signing this agreement I HEREBY RELEASE Releasees from all liability for such loss, damage, or death. I further certify that I am in good health and that I have no conditions or impairments which would preclude my safe entry upon the ALPERT JEWISH COMMUNITY CENTER premises, the use of any of the ALPERT JEWISH COMMUNITY CENTER facilities or equipment, and/or my participation in any of the ALPERT JEWISH COMMUNITY CENTER programs. I further understand, agree and acknowledge that by [submitting this document electronically or by clicking the “I Accept” button below] I become legally bound to this Release, Waiver, Indemnification of All Claims and Covenant Not To Sue – just as if I had signed a hard copy of this Agreement and submitted it to the ALPERT JEWISH COMMUNITY CENTER. *

Parent/Guardian Signature

I accept *

I accept

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