Muckross HC   Covid-19 Questionnaire

Prior to commencing any training with Muckross Hockey Club for the 2020/2021 season, all Senior players must fill in this questionnaire.

Questions are directly as per Hockey Ireland guidelines. If you answer 'yes' to any questions, you must not attend any club activity.

FILL FORM OUT ONCE ONLY – It is up to each individual to re-declare if any change to their health occurs, prior to each subsequent session.  

The form must be submitted before showing up to your first training session with the club.

NO QUESTIONNAIRE – NO TRAINING
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Full Name *
Which Senior Team are you on? *
Do you believe you may have COVID-19? *
Have you been overseas in the last 14 days? *
Have you been in contact with someone who has shown COVID symptoms in the last 14 days? *
Have you had any of the following symptoms of COVID-19 in the past 14 days? *
Yes
No
High Temperature (0ver 37.5 C)
Loss of sense of smell and/or taste
New continuous cough
New unexplained shortness of breath
If you have answered YES to any of the questions above, you must stay home & contact your GP by phone for further advise. If you have answered NO to all of the above questions, you may train and play with your team. Please sign your name to confirm that the details above are true to the best of your knowledge and confirm that you understand the risks involved in participation, are participating on a voluntary basis and that you may opt-out at any time. *
Your Signature/Parent or Guardian's signature if u18
Please provide your email address for contact tracing purposes *
Please provide your phone number for contact tracing purposes *
I confirm that I have read and agree to Muckross HCs COVID-19 guidelines. Signed *
Your signature
Date form completed *
MM
/
DD
/
YYYY
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