GVOC Wednesday Evening Training at Jericho Covid-19 Screening
All participants are required to complete this form. If a parent/guardian is filling in the form for their child, please fill in your name first, and then add the child's name when prompted.
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Child's name (first, then last) if a parent is doing the form for their child who is participating.
Are you experiencing any of the following:
Fever or chills
New or worsening cough
Loss of sense of smell or taste
Extreme fatigue or tiredness
Loss of appetite
Nausea or vomiting
None of the above
Do any of these lifestyle situations apply to you?
Live with someone who has had any of the above symptoms in the last 14 days?
Travelled outside of Canada (including to the USA) in the past 14 days?
Been in contact with anyone confirmed or expected of Covid-19 in the last 14 days?
No to all
Today's date - by clicking this box, it represents your signature.
A copy of your responses will be emailed to the address you provided.
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