COVID-19 Declaration Form for Adult Member
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1. Name of club member: *
2. Please give a contact phone number (for contact tracing): *
3. GP name: *
4. Have you been diagnosed with or do you believe you may currently have COVID-19? *
5. Have you had any of the following symptoms of COVID-19 in the past 14 days? *
6. Have you been in close contact with someone showing symptoms of the virus within the past 14 days? *
7. Have you been advised by a doctor or HSE to cocoon or self-isolate? *
8. Have you read the Galway Shotokan Karate Club COVID-19 Policy (available at *
9. Do you agree to follow all of the guidelines of this policy? *
10. Which classes would you like to join? *
11. Please indicate Temperature as recorded today: *
12. Please sign with your name and date if you understand and agree with above. *
If you have answered YES to any of these questions or if your temperature as recorded today was over 37.5°C, you should stay at home and contact your GP by phone for further advice. If you have answered NO to all of the above questions, and your temperature as recorded today is lower than 37.5°C you may train with your group/pod on the date specified above.
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