LAKESHORE SWIM CLUB COVID-19 SELF-SCREENING HEALTH QUESTIONNAIRE (rev. Aug 2021)
This questionnaire MUST be completed before practice unless you have been informed that the practice facility will conduct the screening questionnaire.
Complete this form regardless of your vaccination status.
The following questions are to ascertained before any in-person training:
Fundamentals Camp (Daily)
Fundamentals Camp (Tuesday & Friday)
None - Attending a Tryout
For practice day
Do you or someone in your household have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.
Fever or chills
Difficulty breathing or shortness of breath
Sore throat, trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Headache that’s unusual or long lasting
Not feeling well, extreme tiredness, sore muscles
In the last 14 days, have you or someone in your household been in close physical contact with someone who currently has COVID-19? This includes getting a COVID Alert exposure notification.
Are you a medical professional and have you been in contact with or cared for someone with COVID-19 in the last 14 days without appropriate medical grade PPE?
I have travelled outside the country within the last 14 days and am required by the Canada Public Health Authority to quarantine/isolation
Someone within my household has travelled outside the country within the last 14 days and I am required by the Canada Public Health Authority to quarantine/isolation
You must answer NO to all the above questions before participating in any in person training session.
If you answer ‘YES’ to any of the above, you cannot participate in the in-person training and you must email
immediately. Follow the COVID safety protocols specified at LSC's COVID Safety Plan web page here:
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Lakeshore Swim Club.