SUMMER 2021 MZAC TORONTO COVID-19 HEALTH DISCLOSURE DECLARATION
NOTE: Updated form as per new regulations from the Ontario government as of June 11, 2021.

Please complete one form per family (living in the same residence).

Prior to entering 30 Pemican Court, please consider the health and safety of others. Access to the building will not be granted for anyone who has either not completed this form or has been unable to check all of the criteria listed below.

Thank you for your cooperation.

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Email *
Contact phone number *
Person 1: Name *
Do you have any of the following new or worsening symptoms or signs? (Check all that apply) Symptoms should not be chronic or related to other know causes or conditions: *
Required
Additional screening questions: *
Required
Person 2: Name
Do you have any of the following new or worsening symptoms or signs? (Check all that apply) Symptoms should not be chronic or related to other know causes or conditions:
Additional screening questions:
Person 3: Name
Do you have any of the following new or worsening symptoms or signs? (Check all that apply) Symptoms should not be chronic or related to other know causes or conditions:
Additional screening questions:
Person 4: Name
Do you have any of the following new or worsening symptoms or signs? (Check all that apply) Symptoms should not be chronic or related to other know causes or conditions:
Additional screening questions:
Person 5: Name
Do you have any of the following new or worsening symptoms or signs? (Check all that apply) Symptoms should not be chronic or related to other know causes or conditions:
Additional screening questions:
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