Adult Covid Screening Checklist
This form will be updated to reflect any Government of Alberta and Alberta Health Services changes to questions and requirements. Due to the Covid-19 outbreak, we are taking extra precautions with the care of every member to include attendance tracking, social distancing protocols and enhanced cleaning procedures in accordance with Alberta Health Services. This form must be filled out EVERY DAY that you are attending Glenmore Gymnastic Club.
I agree that by answering yes to ANY of the questions below, on ANY given day, that I am required to remain at home and will not be allowed to participant in any activities offered by Glenmore Gymnastic Club.
If I do arrive exhibiting any of the symptoms below, the staff at Glenmore Gymnastic Club has the right to refuse entry into the facility. If I develop any of the symptoms listed below while attending activities at the Glenmore Gymnastic Club, staff will implement the rapid response policy.
* Required
Participant Name:
*
Your answer
Participant Phone Number:
*
Your answer
Participant Date of Birth:
*
MM
/
DD
/
YYYY
Have you travelled outside of Canada in the last 14 days? (individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside of Canada)
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Yes
No
Have you had close contact with a confirmed case of Covid-19 in the last 14 days? ( face to face contact within 2 meters)
*
Yes
No
Do you have any new or worsening of the following symptoms?
Fever
Cough
Shortness of breath or difficulty breathing
Runny Nose
Sore throat
Chills
Painful swallowing
Nasal congestion
Felling unwell/fatigued
Nausea/vomiting or diarrhea
Unexplained loss of appetite
Loss of sense of smell
Muscle or joint aches
Headache
Pink eye
None of the above
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