Parent/Junior Self-Assessment Form
To ensure the Health & Safety of all people interacting with our club, all members and visitors must
complete this declaration form prior to entering the club grounds.
Parent/Guardian Name *
Mobile Number *
Email Address
Date *
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Child(ren)'s Name(s) *
Do you or your child(ren) currently have, or have you been diagnosed with COVID-19 in the last 14 days? *
Are you or your child(ren) awaiting results of a test relevant to COVID-19 or are you waiting to have such a test scheduled? *
Have you or your child(ren) or anyone in your household travelled abroad in the last 14 days (with the exception of travel between Northern Ireland and Republic of Ireland)? *
In the last 14 days, have you or your child(ren) displayed any of the following symptoms: fever, high temperature, persistent coughing, breathing difficulties / shortness of breath, and / or loss of taste or smell? *
Do you live in the same household as someone who has displayed symptoms of COVID-19 in the last 14 days or who has a confirmed case of COVID-19? *
Have you or your child(ren) been in close contact with someone (i.e. less than 2 metres for more than 15 minutes accumulative in 1 day) who has displayed symptoms of COVID-19 in the last 14 days? *
Have you or your child(ren) been in close contact with someone (i.e. less than 2 metres for more than 15 minutes accumulative in 1 day) who has a confirmed case of COVID-19? *
Do you think there is any other way you or your child(ren) may have been infected with Covid-19 in the last 14 days? *
Have you or your child(ren) been advised by a doctor to self-isolate at this time? *
Do you or your child(ren) have an underlying health condition or have you or your child(ren) been advised by a doctor to cocoon at this time? If so, please contact the Covid Officer at 087 9313631.
IF YOU HAVE ANSWERED YES TO ANY OF THE QUESTIONS ABOVE, YOU ARE NOT ALLOWED ON THE CLUB’S PREMISES.
I confirm that the above information is accurate to the best of my knowledge.

I confirm that I will contact the Covid Officer (087 9313631) immediately and before my next training session if the answers to any of the questions above changes.

I confirm that I have read the Club Covid-19 Protocol.
Signature Name (Parent/Guardian) *
Signature Date *
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