LSYC Covid-19 Screening Form for Members, Contractors or Visitors
This form is to be completed EACH TIME you plan to attend the Club for ANY REASON.
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Email *
First Name *
Last Name *
Phone Number *
Planned Date of Visit *
1.  Are you currently experiencing any of these as new or worsening symptoms unrelated to an existing or chronic condition? *
Fever and/or chills (temperature of 37.8 degC or higher)
Difficulty breathing or shortness of breath
Sore throat or difficulty swallowing
Runny or stuffy nose
Decrease or loss of sense of taste or smell
Headache, muscle aches
Digestive upset (nausea, vomiting, diarrhea, abdominal pain)
2.  Has a doctor, health care provider or public health unit told you you should currently be isolating (staying at home)? *
3.  In the last 14 days, have you been in close contact with a suspected or confirmed case of Covid-19? *
4.  In the last 14 days, have you traveled outside of Canada? *
Did you answer "Yes" to any of the above questions?
If you answered "Yes" to any of the above questions , DO NOT come to or remain at the Club.  Self-isolate at home and contact your health-care provider or Telehealth Ontario at 1-866-797-0000 to find out if you need a Covid-19 test.

Please direct questions or concerns to the Vice Commodore.

If you are a contractor or visitor, please provide the name of the Member you will be meeting.
If you are unfamiliar with the Club's Covid-19 safety protocols, please consult that Member prior to your visit.
I warrant that I have answered the above questions honestly and to the best of my knowledge, and agree to abide by the Club's Covid-19 safety protocols during the time I am on Club property. *
Should you choose to disagree, DO NOT come to or remain at the Club!
Thank you for your co-operation!
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