River Heights Site COVID-19 Screening Form
This online declaration must be completed each day you are visiting the facility.

Please complete prior to entering the facility. If not completed, we will require a verbal declaration to be completed upon arrival.

Self-Assessment Tracking Form

By filling in my name, answering the questions and clicking OK, I hereby declare that I have fully read and understand the Corydon Community Centre COVID-19 Procedures and will adhere to them at all times while present at the Centre.

I agree that should I answer YES to any of the questions on the Self-Assessment tool, I will not be present at the Centre and follow the advice of Shared Health Manitoba, such as seeking further medical advice or self-isolating.

I agree that under no circumstances will I be present at the Centre if showing any symptoms of COVID-19 or general illness, nor have I recently traveled out of province or am under direction to self-monitor or self-isolate.

I agree that Management at Corydon Community Centre reserves the right to refuse entry if they feel you are in violation of procedures and protocols.

I understand that until I have completed this declaration, I will not be permitted to be present at Corydon Community Centre.

Please note that the COVID-19 Protocols will be subject to change without notice and everyone must complete their own due diligence to ensure they remain up to date on changes to policies and procedures.

Name of Participant *
Name of Parent/Guardian (if under 18) *
Phone Number *
Type of Program *
Time of program (24 Hour Clock)? *
Time
:
Do you have a new onset of any of the following symptoms: fever/chills, cough, sore throat/hoarse voice, shortness of breath, loss of taste or smell, vomiting, or diarrhea for more than 24 hours? *
Do you have a new onset of 2 or more of any of the following symptoms: runny nose, muscle aches, fatigue, conjunctivitis (pink eye), headache, skin rash of unknown cause, nausea or loss of appetite? *
Have you been in contact with a probable case of COVID-19 in the last 14 days? *
Have you left the province in the last 14 days? (excluding Western Canada, the territories, or Ontario west of Terrace Bay) *
Have you been in a setting in the last 14 days that has been identified by public health as a risk for acquiring COVID-19, such as on a flight, in a workplace with a cluster of cases, or at an event? *
Have you been asked to self-isolate? *
Waiver Agreement
If you answered YES to any of the questions, you will NOT BE PERMITTED to enter Corydon Community Centre.

For more information about caring for yourself at home and self-isolating, visit: manitoba.ca/covid19/factsheets. If you have more questions, please call Health Links-Info Santé in Winnipeg at 204-788-8200; toll free elsewhere in Manitoba 1-888-315-9257.

By clicking the SUBMIT button below I agree that should I answer YES to any of the questions on the Self-Assessment tool, I will not be present at the Centre and follow the advice of Shared Health Manitoba, such as seeking further medical advice or self-isolating. I agree that under no circumstances will I be present at the Centre if showing any symptoms of COVID-19 or general illness, nor have I recently traveled out of province or am under direction to self-monitor or self-isolate. I agree that Management at Corydon Community Centre reserves the right to refuse entry if they feel you are in violation of procedures and protocols. I agree that if I am found to have failed to comply with the protocols and self-assessment tools, I will be subject to an immediate suspension. I understand that until I have completed this declaration, I will not be permitted to be present at Corydon Community Centre.
Submit
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