Health Declaration Form

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For our safety, please complete the form honestly 24 hours before your scheduled appointment. You may only enter the studio if you have completed the form and ticked "YES" to all the questions. For updates on how we are keeping our clients and studio safe, visit http://rebrand.ly/MadeToMovePilatesSG. Thank you for your cooperation and we will get through this together! (Updated 17 June 2020)

Indicate your Full Name as per NRIC *

Indicate your mobile number *

TRAVEL DECLARATION: I confirm that i have NOT travelled in the last 14 days to any country and DO NOT have a Stay Home Notice (SHN). *

YES

"ZERO" CONTACT DECLARATION: To my knowledge, I confirm that I DO NOT have contact from anyone who has the virus, or to anyone who has travelled in the last 14 days or has been issued a Stay Home Notice (SHN) from the Singapore Government. *

YES

MEDICAL DECLARATION: I declare that I DO NOT have ANY of the following symptoms in the last 14 days - fever, sore throat, cough, flu-like symptoms such as running nose or headache, unexplained shortness of breath) *

YES

COMPLIANCE DECLARATION: I comply to all the necessary measures the studio will do for our safety such as a. taking my temperature if necessary b. Fill up this form before the 1st class (one time only on Phase 2) c. update my medical status 6 hours before class d. use the hand sanitisers provided or use water/soap when necessary e. Comply with social distancing measures *

YES

Other:

I have downloaded the Trace Together App https://www.tracetogether.gov.sg/ and will ensure its opened during the session *

YES

I ticked 'YES' to all the above questions and agree to all the necessary measures Made to Move Pilates will do to prioritise our safety based on the evolving landscape. I confirm that all the above information is true and correct as of the date indicated below. *

YYYY

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