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Participant Screening for Behind the Wheel Lessons - Under 18

February 28, 2021

Student’s Name:

Please Answer the following questions prior to each lesson:

Do you have any symptoms associated with COVID - 19? YesNo
Have you tested positive for COVID - 19? YesNo
Have you been in close contact with anyone that has tested positive or exhibited symptoms from COVID - 19 in the last 14 days? YesNo
Temperature at the start of the lesson:

**A yes answer to any of the questions or a temperature of 100 or more will not be allowed to participate.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

October 2, 2020 3:30 pm EST

Participant Screening for Behind the Wheel Lessons - Under 18 Uploaded by Premier Driving School, Inc - service@premierdriversed.com IP 100.16.21.104