COVID-19 Screening and Contact Tracing Declaration - April 2021
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To ensure the Safety & Health of all people interacting with our club all members, coaches and visitors must complete this declaration form prior to participation in club training, commencing w/o 12 April 2021.

If you indicate a positive answer to any of the COVID-19 screening questions below, you should not attend training and are advised to seek professional medical help/assistance.

You should fill this in advance of attending your first training session.  You may be asked to check in and re-confirm that your answers have not changed.  

Please advise a BKA Club Coach/representative immediately if your circumstances change and you are no longer in a position to answer 'No' to all yes/no questions below.

Please complete a new online form if your circumstances change.

For children under 18, this form should be completed by a parent/guardian.

Name of Club Member, Coach, Visitor or Open Day participant *
Age - if completing for a Child *
Club Member, Coach or Visitor? *
If you are a new member or an Open Day participant, how did you learn about Belfast Kayak Academy *
Mobile Phone Number for Contact Tracing *
Email Address for Contact Tracing *
CANI / British Canoeing / Canoeing Ireland / Other Membership Number (if known)
Is this your first declaration or an update?  Only provide an update if your circumstances have changed *
Do you have any of the symptoms of COVID 19 - for example cough, fever, high temperature, sore throat, runny nose, loss of smell, breathlessness or flu-like symptoms now or in the past 14 days? *
Have you been diagnosed with a COVID-19 infection in the last 14 days? *
Have you been in contact with anyone who has been diagnosed with COVID-19 in the last 14 days? *
Are you self isolating or been advised to self isolate at this time?  This includes isolation as a requirement of travel. *
Any other comments?
I understand that this information is required for the purposes of public health. I confirm that the above information is true and accurate from the date of signing. I understand that the personal information given by me above, including my name and contact details, may be shared with the relevant health professionals for the sole purpose of contact tracing, in line with public health guidelines.  I agree to verbally affirm these answers before attendance at club training.  I agree to update the Club verbally and by completing a new online form, if any of the information provided above changes.  I agree to the information provided in this form, being kept on file for the duration of the COVID-19 restrictions. *
Required
Agreed by (type your name to affirm agreement). Parent/Guardian to agree for children under 18. *
Date *
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