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Russell Aquatics COVID-19 Health Screening
To be completed each time before entry into the swim school. This form must be completed by the person dropping off the child - If you are experiencing any symptoms, we kindly ask that you stay home, give us a call (905-471-6767) or send us an email (
) and a member of our team will be happy to discuss options with you. Please note that we reserve the right to end classes if any health concerns arise.
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Child(ren)'s First and Last Name:
Name of Accompanying Guardian & their relation to the student(s) (only one per family):
Today's Date: *
Phone Number: *
Do you or the student have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions. If any symptoms are noted, we ask that you stay home. The individual should stay home and not leave except to get tested or for a medical emergency. Talk with a doctor/health care provider for medical advice.
Fever and/ or chills (temperature of 37.8°C/ 100°F or higher)
Cough or barking cough/ croup (continuous, more than usual, making a whistling noise when breathing - not related to asthma or other known conditions)
Shortness of breath (out of breath, unable to breathe deeply - not related to asthma or other known conditions)
Decrease or loss of taste or smell (not related to seasonal allergies, neurological disorders or other known conditions)
Nausea, vomiting and/or diarrhea (not related to IBS, anxiety, menstrual cramps or other known conditions)
None of the Above
Are you, your child(ren) or anyone you've knowingly been in contact with currently waiting for COVID-19 test results?
Yes but I have not been advised to do so and am doing so for work, to visit a loved one, etc.
If you selected the third option, please explain.
Have you or your child been identified as a close contact of someone who is confirmed to have COVID-19 by your local public health unit?
Have you or your child been directed to self isolate by a health care provider or public health official?
If you answered yes to any of the above questions or are experiencing any symptoms, we kindly ask that you do not attend lessons today and reach out to our administrative team to arrange for a make-up class. We appreciate your understanding and co-operation!
Yes - I agree that all information is accurate and true. I understand that if my child(ren) present symptoms during their lesson, staff reserve the right to end the lesson immediately.
A copy of your responses will be emailed to the address you provided.
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