COVID 19

Full Name

Phone Number

Are you an instructor or user? Are you an instructor or user? Instructor Participant Guest

Have you or someone you've been with traveled out of the country in the last 14 days? Have you or someone you've been with traveled out of the country in the last 14 days? Yes No

Has a doctor or specialist told you that you should be isolated at this time? Has a doctor or specialist told you that you should be isolated at this time? Yes No

In the last 14 days have you been in close contact with someone who has COVID? In the last 14 days have you been in close contact with someone who has COVID? Yes No

Are you or someone you live with waiting for COVID test results or experiencing symptoms? Are you or someone you live with waiting for COVID test results or experiencing symptoms? Yes No

Are you experiencing any of these symptoms? Are you experiencing any of these symptoms? Fever over 37.8 or chills Dry or wet continuously cough Difficulty breathing or deep breaths Lack of smell or taste Sore throat swelling Pain Congested nose Unusual or long term headache Nausea, vomiting, diarrhea Extreme tiredness or muscle pain None of the above

I give my consent to participate in activity with rebound boots. I understand that this exercise is not a science and there are no guarantees of the benefits received or the safety of my participation in this program. I also understand that there may be risks associated with the use of this exercise machine and with exercise in general, which cannot be avoided. Once the proper use of the equipment is indicated, I must use it with caution. I acknowledge that this program involves vigorous physical activity, including cardiac and muscular strength and endurance. I certify that I am in good physical coordination and do not have a disability that prevents me from participating in this program. My participation in this program is voluntary and not mandatory by Ejercicio de Rebote Mexico SA de CV / Salta Mexico and/or Alejandra G. Leyva. Finally, releasing the organization from all responsibilities. I give my consent to participate in activity with rebound boots. I understand that this exercise is not a science and there are no guarantees of the benefits received or the safety of my participation in this program. I also understand that there may be risks associated with the use of this exercise machine and with exercise in general, which cannot be avoided. Once the proper use of the equipment is indicated, I must use it with caution. I acknowledge that this program involves vigorous physical activity, including cardiac and muscular strength and endurance. I certify that I am in good physical coordination and do not have a disability that prevents me from participating in this program. My participation in this program is voluntary and not mandatory by Ejercicio de Rebote Mexico SA de CV / Salta Mexico and/or Alejandra G. Leyva. Finally, releasing the organization from all responsibilities. Yes, I do No

I personally verified that I have answered truthfully and understand the consequences of giving false information. I personally verified that I have answered truthfully and understand the consequences of giving false information. I confirm that the information in this questionnaire is true.