In Person Visitation- COVID19 FORM

Please fill out prior to your visit. If you have any questions please call Michelle, Director of Recreation at 718-514-8384


As a safety precaution, all persons entering this facility are required to attest and affirm the following:
i) No Signs or symptoms of a respiratory infection, such as fever above 100.4 degrees, cough, shortness of breath, or sore throat.
ii) NOTICE: You are advised to monitor for signs and symptoms of respiratory infection for at least 14 days after exiting the location. If symptoms occur, self-isolate at home, contact your healthcare provider, and immediately notify the facility of the date you were in the facility, the individuals you were in contact with, and the locations within the facility you visited.
iii) NOTICE: Upon entering the location, you attest that you self-monitored for signs and symptoms of a respiratory infection, such as fever, cough, shortness of breath or sore throat last night or 12 hours ago.
iv) Visitation will be refused if the individual(s) exhibits any COVID-19 symptoms or do not pass the screening questions. Screening shall consist of both temperature checks and asking questions to assess potential exposure to COVID-19 which shall include questions regarding international travel or travel to other states designated under the Commissioner’s travel advisory. Visitors will be required to complete the screening process prior to each visit. No food or other packages will be allowed for exchange at this time.
v) The individual cleared the screening (both temperature and questions) YES ___ NO ___

vi) Temperature: _________Degrees

vii) A valid Driver’s License will be required to verify proof of address.
  • Date Format: MM slash DD slash YYYY
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