Covid Screening Form

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Please submit this Covid screening before attending each session to help us keep your family and our clinic safe.
If you answer 'Yes' to any of the below, please do not enter the premises but contact the office at 289 678 0581 to switch to a virtual session or to reschedule your appointment.

Email *

Date *

YYYY

Name *

Are you currently experiencing any of the following NEW or WORSENING symptoms that are NOT related to other known causes or conditions (eg allergies, chronic conditions): *

Fever - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Runny or stuffy nose

Cough (barking cough, whistling when breathing)

Shortness of breath

Chills

Sore throat or difficulty swallowing

Decrease or loss of taste or smell

Pinkeye/Conjunctivitis

Headache that is unusual or long-lasting

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Muscle aches that are unusual or long-lasting

Extreme tiredness that is unusual

Sluggishness and lack of appetite

None of The Above

Have you travelled out of Canada in the past 14 days? *

Yes

Have you tested positive for Covid-19 in the past 14 days? *

Yes

In the last 14 days, have you been in close physical contact with someone who currently has a confirmed case of COVID-19?(This includes getting a COVID Alert exposure notification. Close physical contact means: being less than 2 metres away in the same room, workspace, or area; living in the same home; being in the same classroom)? *

Yes

PARENTS BRINGING CHILD/REN TO A PROGRAM: I acknowledge that I am responsible for applying sunscreen to my child prior to arrival. I consent to NowWhat Staff reapplying paraben-free, scent-free sunscreen to my child as needed throughout the day (NowWhat will provide the sunscreen to limit the number of personal items on site). *

I understand and agree to the NowWhat sunscreen policy

This does not apply to me (applies only to guardians of children in outdoor programs)

Other:

Send me a copy of my responses.

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