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R.B.A.I. RUGBY CLUB
COVID-19 Declaration Form
This form must be completed and submitted to your club/school before each and every rugby activity (e.g. training or match). Should you answer YES to any of these questions, you should NOT attend your club.
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* Indicates required question
Full Name
*
Your answer
Please select the team you will be training with
*
1st XV
2nd XV
3rd XV
Medallions
U14
U13
U12
Please select the date of your activity
*
Choose
03/10/20
10/10/20
17/10/20
21/11/20
12/12/20
Have you been identified by Public Health as a close contact of a confirmed case of COVID-19 in the past 14 days?
*
Yes
No
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?
*
Yes
No
Have you been advised by a doctor to self-isolate or restrict movement at this time?
*
Yes
No
Are you feeling unwell, have felt unwell in the past 48 hours or have any common symptom of COVID-19 including:
*
Fever or High Temperature
A New Continuous Cough
Unexplained Breathing Difficulties Or Shortness Of Breath
Loss or change to your sense of smell or taste
No
Required
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