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Mandarin Badminton Club Health and Screening Disclosure Form
This form must be completed by each individual prior to entry into the club. A participant who answers "YES" to any of the questions in the form will be refused entry into the club as public health requires you to be isolating at this time.
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* Indicates required question
Email
*
Your email
Full Name (Last, First)
*
Your answer
Phone Number
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
Have you received your second Covid vaccine?
*
Yes
No
Are you currently experiencing any of these symptoms? Choose any all that are new, worsening, and not related to other known causes or conditions you already have
*
Fever and/or chills: 37.8 degrees Celsius or higher body temperature
Cough or barking cough
Shortness of breath
Sore throat
Difficulty swallowing or breathng
Runny or congested nose
Decrease of less of taste or smell
Pink eye
Headache
Digestive issues
Nausea/vomitting
Unusual, long-lasting muscle aches not related to a sudden injury or previous condition
Extreme tiredness
None of the above
Required
In the last 14 days, have you or anyone you live with travelled outside of Canada? If exempt from quarantine requirements (i.e. essential worker who regularly crosses the border for work), please select "No"
*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?
*
Yes
No
Has a doctor, health care practitioner, or public health unit told you that you should currently be isolating or staying at home due to an outbreak, symptoms, or contact tracing?
*
Yes
No
In the last 14 days, have you received a COVID alert exposure notification on your cell phone? If you have received the alert but have gotten a confirmed negative PCR test result, please select "No"
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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