Liffeybank FC COVID & Academy Assessment Form

This data is collected for the sole purpose of contact tracing and ensuring COVID19 health screening prior to arrival at Liffeybank FC Academy Training sessions. All data will be held for for contact tracing purposes and Academy reference.

Located is in St. Catherine's Park - https://goo.gl/maps/nSzA9phkKcu8UaBa7

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Parent or Guardian's Name *
Phone Number *
Player's First Name *
Player's Surname *
Player's Date of Birth *
MM
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DD
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YYYY
Session Date *
MM
/
DD
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YYYY
I accept risks involved / posed by COVID19 and that risk cannot be eliminated *
I confirm that the participant is not showing signs of COVID19 (See symptoms graphic below) *
The participant has not been advised to self isolate by a medical professional *
The participant has not had COVID19 in the past 14 days *
This data can be used for contact tracing if needed (if you answer no, the player cannot take participate in the session) *
I, the parent/guardian of (the player named on this form), hereby certify that the player is in good health and has no physical or other conditions that affect the player's ability to fully participate in the Liffeybank FC Academy and have not been advised otherwise by a medical practitioner. I understand that there is a risk of injury to the player as a result of her participation in the sport at the Academy, and I knowingly and voluntarily assume all risk of such injury. I authorize emergency medical treatment deemed necessary by medical personnel if the player is not able to act on her own behalf. *
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