Covid-19 Vaccination & Consent Form

Fort Pilates has adopted the CDC’s recommendations and will be holding classes at full capacity again!

While will still be following our COVID-19 protocol for mask wearing, hand and equipment sanitizing, and ventilation - the size of our studio means we will no longer be able to accommodate the recommended 6’ for social distancing. For the health of our staff and clients, we are asking that all in-person class participants be vaccinated.

Fort Pilates is committed to our clients’ privacy and will not share the information below. We thank you for understanding the unique circumstances of being a small studio. We are excited to be back practicing together as a community!

By signing the waiver below you acknowledge that you will no longer be socially distanced from other clients in classes. In addition, you are confirming that you are fully vaccinated (having received 2 doses of Pfizer-BioNTech or Moderna, NIAID vaccine or 1 dose of the J&J/Janssen vaccine).

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Date of Second Vaccine Dose

If you received a vaccine that is only one dose, please put the date of your single dose.

MM

DD

YYYY

County or State Vaccinated

If outside of NY please list the state you received your vaccination from:

BY ELECTRONICALLY SELECTING “ACCEPT” you affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of your knowledge and belief.

ACCEPT

DO NOT ACCEPT

* Required