Covid 19 - Health Form - Lakers Events

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Please complete this within 48 hours of the Event Date

Email *

Name of Participant *

Date *

YYYY

To the best of your knowledge have you been in close proximity with anyone who has Covid-19? *

Yes

Has anyone in your household been tested for Covid-19 in the last 14 Days? *

Yes

Do you have any reason to believe that you or anyone in your household has been exposed to or acquired COVID-19 *

Yes

Have you or anyone in your household had any of the following symptoms in the last 14 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, or high temperature? *

Yes

Have you or anyone in your household travelled outside of Ireland in the last 14 days? (Lakers asks that at least 5 days pass before you join our events if you have travelled) *

Yes

Have you or anyone in your household been asked to self isolate by a medical practitioner? *

Yes

Is the information you provided correct to the best of your knowledge? *

Yes

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