u18 Cobh Pirates RFC: PRE-RUGBY PERSONAL ASSESSMENT DECLARATION
This form must be completed by the player's parent/guardian on behalf of the player and submitted to the club before each and every rugby activity (e.g. training or match). Should you answer YES to any of questions 1-5, the player should NOT attend your club. For question 6, the latest government travel advice applies. Before the player resumes, the player should follow appropriate medical advice and guidelines.
Enter the u18 player's name: *
Please input the date the u18 player will be attending the Paddocks for training, match or a Club event. *
MM
/
DD
/
YYYY
1. Is the player a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day) *
2. Has the player been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *
3. Has the player been advised by a doctor to self-isolate at this time? *
4. Has the player been advised by a doctor to cocoon or shield at this time? *
5. Is the player suffering now, or has the player suffered any the following symptoms in the past 14 days? *
Yes
No
Cough
Fever
High Temperature
Sore Throat
Runny Nose
Breathlessness
Loss of Smell/Taste
New Skin Rash
New Gastrointestinal symptoms
Flu Like Symptoms
6. Has the player returned to Ireland from another country within the last 14 days? *
If yes to travel outside Ireland, where did the player visit?
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