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["軽井沢風越公園　施設利用者　健康チェックシート"]
[]
[]
["利用日時",null,null,null,"年",null,"月",null,"日"]
[]
["利用施設",null,"アイスアリーナ　　　スカップ軽井沢　　屋外テニスコート　　グラウンド"]
[]
[null,null,"スケートリンク　　　　カーリングホール　　　総合体育館"]
[]
["利用名称"]
[]
[null,"氏　　　名","性　別","年　齢","住　　　所",null,null,null,"連絡先",null,"体　温","体　調"]
[1,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[2,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[3,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[4,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[5,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[6,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[7,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[8,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[9,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[10,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[11,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[12,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[13,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[14,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[15,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[16,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[17,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[18,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[19,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[20,null,"男　女",null,null,null,null,null,null,null,null,"良　否"]
[]
[null,"いただきました個人情報は、公園内にて感染が発覚した場合の連絡・調査以外には使用いたしません。"]
[]
[]
[null,null,null,null,null,"記入者氏名（自筆）"]