KAP sani2c 2021 COVID SCREENING - Race
THIS FORM MUST BE COMPLETED BEFORE ARRIVING AT GLENCAIRN FARM.
IF YOU DO NOT COMPLETE THIS FORM YOU WILL NOT BE GRANTED ACCESS UNTIL COMPLETED.
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FIRST NAME *
LAST NAME *
ID NUMBER *
MOBILE NUMBER
GENDER
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DATE *
MM
/
DD
/
YYYY
SYMPTOMS
Cough *
Sore Throat *
Shortness Of Breath *
Nausea/Vomiting/Diarrhoea *
Fever/Chills OR High Temperature (37.5°c +) *
Loss Of Taste *
Loss Of Sense Of Smell *
Body Aches *
Fatigue/Weakness/Tiredness *
Persistent Pain Or Pressure In The Chest *
Have you had contact with anyone with cold/flu like illness in the last 14 days? *
Have you been diagnosed with the Corona virus infection in the last 14 days? *
Have you had any contact with a confirmed COVID-19 case in the last 14 days? *
By completing and submitting this form, I hereby indemnify and hold harmless KAP sani2c, all entities associated with the the event, the owner/s of any property on which the event is held, and their respective staff and crew, against any legal liability should I contract COVID-19 during the competition, regardless of the precautions taken to mitigate the risk. I understand and accept that I am present at the event at my own risk. *
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