CLBC COVID-19 Health Declaration Form for Children (age 17 and under)
* Details of this health declaration will be kept in record securely by CLBC to help support contact tracing, as per Toronto Public Health guidance.
* 跟據多市衞生部指引，教會將小心保存已提交健康申報表，以支援衞生部在有需要下聯絡出席者。

* The Form is to be filled out on the same day prior to every meeting, at most two hours in advance.
* 申報表應在參加聚會當日最多兩小時前提交。

* Anyone with even one symptom of COVID-19 should get tested and stay home.
* 如肢體有任何一種 COVID-19 徴狀，請留在家中。
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Attention: Please follow the sequence to enter Last name and First name.  Please also use the last name from your household.  This sequence helps us to sort name list.  留意：請跟從姓名填寫次序，也留意使用你家庭姓氏。這次序幫助我們排列名單。
Child's Last name, First name　孩子姓名 *
Parent/guardian's Last name, First name 家長／監護人姓名 *
Parent/guardian contact number 家長／監護人電話號碼 *
Date　日期 *
MM
/
DD
/
YYYY
Does the child/student have any of the following new or worsening symptom 　您是否有以下任何新的或惡化的症狀:
» Fever (A fever is a temperature of 37.8C or greater) or chills 發熱（體溫在 37.8C 或以上為發熱) 或發冷
» Cough 咳嗽
» Difficulty breathing 呼吸困難
» Decrease or loss of taste or smell 失去味覺或嗅覺
» Nausea, vomiting, diarrhea 噁心, 嘔吐, 腹瀉
If the child/student has a health condition diagnosed by a health care provider that gives them the symptom, answer “No”. If the symptom is new, different or getting worse, answer “Yes”.  如果兒童/學生的健康狀況由醫療保健提供者診斷出並導致他們出現症狀，請回答“否”。 如果症狀是新的、不同的或惡化的，請回答“是”。
Anyone who is sick or has any symptoms of illness, including those not listed above, should stay home and seek assessment from their health care provider if needed.  如果兒童/學生生病或有任何疾病症狀，包括上面未列出的症狀，請留在家中並在需要時向您的醫療保健提供者尋求評估。
Does anyone in your household have one or more symptoms of COVID-19 and/or are waiting for test results after having symptoms? 您家中是否有人有一種或多種 COVID-19 症狀和/或在出現症狀後正在等待檢測結果？
• If the child/student is fully vaccinated or has tested positive for COVID-19 in the last 90 days and been
 cleared, answer “No”. 如果孩子/學生已完全接種疫苗或在過去 90 天內檢測出 COVID-19 呈陽性並被清除，請回答「否」。
In the last 10 days, has the child/student tested positive on a rapid antigen test or a home-based self-testing kit? 在過去 10 天內，孩子/學生是否在快速抗原檢測或家庭自檢試劑盒中檢測呈陽性？
• If the child/student has since tested negative on a lab-based PCR test, answer “No.” 如果此後孩子/學生在實驗室的 PCR 測試中檢測結果為陰性，請回答「否」。
Has the child/student been notified as a close contact of someone with COVID-19 or been told to stay home and self-isolate? 孩子/學生是否被告知與 COVID-19 患者有密切接觸或被告知待在家裡並自我隔離？
• If the child/student is fully vaccinated or has tested positive for COVID-19 in the last 90 days and been cleared or public health has said the child/student does not have to self-isolate, answer “No”. 如果兒童/學生已完全接種疫苗或在過去 90 天內檢測出 COVID-19 呈陽性並被清除，或者公共衛生部門表示兒童/學生不必自我隔離，請回答「否」。
In the last 14 days, has the child/student travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements? 在過去的 14 天內，孩子/學生是否曾在加拿大境外旅行並被建議按照聯邦檢疫要求進行檢疫？
If you answered “YES” to any of these questions, go home & self-isolate right away.  Call Telehealth or your health care provider, to find out if you need a test.  如以上問題答案有“是”，請馬上留在家中自我隔離，並聯絡 Telehealth 或你的醫療支援服務以確定是否需要進行測試。
I confirm that I do not have any symptom or situation mentioned above. 本人確認沒有以上病徵或情況。 *
Required
Attention: This form is to be filled out on the same day prior to every meeting, at most two hours in advance.
注意：申報表應在參加聚會當日最多兩小時前提交。
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