Health-Check Form - Arhanta Yoga

Name(Required)

Please enter your full name

Living environment(Required)

Are you, or is your family/partner, currently experiencing any of the following symptoms:

Coughing

Fever

Shortness of breath

Loss in smell or taste

Symptoms of the common cold / Other

Covid-19(Required)

Have you had and/or recovered from the Covid-19/Corona disease in the last 14 days?
If your answer below is 'Yes' or 'Maybe', please send us an email with details so we can assess your situation.

Yes, confirmed by testing. But I have recovered and have no symptoms anymore for at least 7 days.

Yes, self diagnosed. (not tested)

Maybe, I have/had symptoms within the last 7 days.

Maybe, I had symptoms but not anymore for at least 7 days.

Maybe, I have been in direct contact with someone who had symptoms in the past 14 days.

No. I have not had the Corona / Covid-19 disease.

No. I (might) have had Corona before the 31th of August 2022 and recovered fully.

Risk(Required)

Are you part of a risk group?

Yes, by age (over 50)

Yes, I have medical issues.

Yes, other reasons (please let us know by email)

Additional details

Please inform us in case there are any important details we should know about. Such as medication, past injuries, travel plans, etc.
We recommend you to arrive at 11:00AM. If your travel plan (train/plane) requires you to arrive after 12:00PM, you can inform us here.

Emergency Contact

Please fill in the name and phone number of the person we should contact in case of an emergency. (including country code if outside The Netherlands)

Declaration:(Required)

Please mark all 4 of the following statements, or contact us immediately in case you disagree with any of them.

Yes I understand the risk involved in coming together as a group to study.

I understand that in the event of developing any covid-19 symptoms I will do a self-test. In case of a positive test result I will have to self-isolate at my own cost until I am symptom-free and have tested negative for Covid-19.

I confirm that I have filled in this form truthfully and will update Arhanta Yoga Ashrams in case any of the provided information changes.

I confirm that I have read and agreed on the Rules & Regulations, Refund policy, terms & conditions and liability waiver of Arhanta Yoga. ( General conditions + Liability waiver )

Covid-19 Questions