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ROW Swim Club Health Attestation Form - Try-outs
Mandated COVID19 Health Screening and Contact Tracing Questionnaire
Please fill out this form for each Swimmer participating in the try-out.
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* Indicates required question
Email
*
Your email
Date of Swim Session
*
MM
/
DD
/
YYYY
Swimmer’s Last Name
*
Your answer
Swimmer’s First Name
*
Your answer
Do you (the Swimmer) have any of the following symptoms?
*
Fever
Cough
Shortness of Breath/Difficulty Breathing
Sore Throat
Chills
Painful Swallowing
Runny Nose/Nasal Congestion
Feeling Unwell/Fatigued
Nausea / Vomiting / Diahrrea
Recent Loss of Taste or Smell
Muscle / Joint Aches
Headache
Red Irritated Eyes
Any new Rashes especially on Hands or Feet
NO TO ALL ABOVE LISTED SYMPTOMS
Required
Have you (the Swimmer) or anyone in your household travelled outside of Canada in the last 14 days?
*
Yes
No
Does anyone in your household feel unwell with any of the above symptoms?
*
Yes
No
Have you (the Swimmer) or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?
*
Yes
No
Name of parent filling in this questionnaire
*
Your answer
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