Screening Form

McClellan COVID & Waiver

Name *

First

Last

Phone *

Email *

Status *

Rank *

Unit *

Have you been in contact with anyone exposed to COVID-19? *

Yes
No
Not sure

Have you been out of state in the past 30 days? *

Yes
No

Emergency Contact

Name *

First

Last

Phone *

Release from Liability. In consideration for being allowed to participate in the fitness programs, and use of the facilities and equipment at Joint Base Langley- Eustis (Fort Eustis) gyms, (hereinafter, “Premises”), I hereby, voluntarily and unconditionally, release the United States Government, including all of its subdivisions, officers, military personnel, employees, instructors and agents, from liability for any personal injury or death that may result from my participation in these programs or the use of these facilities or equipment. Medical Condition. I affirm that I am in good health and possess no physical limitation that would preclude safe participation in activities at the Premises to myself or others. I understand that I should consult a physician or other medical professional before participating in activities or use of equipment. I acknowledge that although I should inform fitness staff if I have a previous injury or profile in order to receive adequate training to prevent further injury, that I assume all risks for participating in activities or use of equipment at the Premises. Assumption of Risk. I understand that activities at the Premises are inherently dangerous and that not all hazards or risks can be fully eliminated. After the opportunity to fully inform myself about activities conducted at the Premises, I knowingly, voluntarily, and freely assume and accept the risk of injury, illness, death, or property damage or loss resulting from activities associated with the use of the Premises, both known and unknown, even if arising from the negligence, or act or omission of the U.S. Government and/or its officers, employees, volunteers, or successors. Compliance with Safety Rules. I agree to comply with all rules and regulations, all safety policies, guidance and warnings incident to participation in activities at the Premises. Facility management reserves the right to evict, revoke or terminate privileges of participants that fail to keep or obey any such rules or regulations. I agree that it is my sole responsibility to be familiar with the equipment, the safety rules, and any physical limitations I may have in order to safely participate in activities conducted at the Premises. *

Agree
Disagree

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Like this:

Rec Center Screening Form

Emergency Contact

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Emergency Contact

Aquatics Screening Form

Emergency Contact

Form is required to be filled once a week.

Aquatics Screening Form

Emergency Contact

Form is required to be filled once a week.

ITT Screening Form

Emergency Contact

McClellan COVID & Waiver

Emergency Contact

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