Covid19 agreement form

I’m really excited to welcome you back to indoor gong meditations. Although some things have changed my commitment to hold gong meditations for your benefit remains.

Following the COVID-19 pandemic, and in line with government guidelines I have put extra measures in place for the safety of you and me.

The numbers of participants are limited in all the venues to keep sufficient physical distancing between everyone (more than 2 meters).
I will be wearing a mask and will remove it while I talk at the beginning and the end of the gong meditation so everyone can hear me.
Please wear a face covering while entering and exiting the venue and in communal areas such as corridors and toilets, where physical distancing is not possible. Once you find your space, please stay in one place and if you prefer, you can remove your face covering. I know it's not easy to relax for an hour with the face covering. If you are exempt from wearing a face covering, then please disregard the above guidelines on face coverings.
Each venue has high hygiene standards and rooms are cleaned and aired before and after each use.

Please carefully read and answer the following questions. This information will be stored confidentially and securely for 21 days.

Personal Details

* Indicates required field

Name *

First

Last

Email *

Event *

Phone Number *

Date of the event *

Testing

Have you had Covid19 test? *

If 'yes', what was the date: *

If positive, has the isolation period finished? *

Do you still have symptoms / after effects? *

If 'yes', please give details: *

Symptoms – Are you experiencing any of the following?

Do you have a new or persistent cough? *

Are you experiencing any chest pain or shortness of breath? *

Do you have a new, unexplained rash? *

Do you have a fever (temp above 37.8°c)? *

Have you lost or experiencing a reduced sense of taste or smell? *

Do you have any gastrointestinal symptoms such as diarrhoea? *

Exposure to Covid19

Have you been in contact with anyone with Covid19 symptoms? *

Are you an NHS front line worker? *

Are you shielding a vulnerable person? *

Are you living with anyone who is self-isolating due to Covid19 symptoms? *

Are you a carer – in the community or care home? *

AGREEMENT

I have understood, read and completed this form truthfully to the best of my knowledge.
I knowingly and willingly consent to participate in the event during the COVID19 pandemic.
I confirm to my knowledge that I; my household or social bubble have not been in contact with anyone that has had symptoms of COVID19 in the last 14 days.
To prevent the spread of the virus and protect each other, I confirm that I will strictly follow guidelines given to me by Monika.

Your name *

Date *

If you display any Covid19 symptoms as per NHS website (https://www.nhs.uk/conditions/coronavirus-covid-19/symptoms/), please get in touch with me and do not attend the event. Your payment can either be transferred to a later date or refunded in full.

GDPR:
The data collected on this form will be used for the sole purpose of Rainbow Vibrations gong meditations and will not be disclosed to any external sources. This form will be kept for 21 days.

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