MHCP - COVID 19 Screening and Contact Tracing Declaration
To ensure the Safety & Health of all people interacting with our club, polo family and wider community, all event participants and visitors must complete this declaration form prior to participation in any training session or event.

If you indicate a positive answer to any of the COVID-19 screening questions below, you should not
attend training or events at Mullingar Harbour Canoe Polo Club and are advised to seek professional medical help/assistance.

If you fill this in in advance of attending, you will be asked to check in and re-confirm that your answers have not changed.  Please advise a Club representative immediately if your circumstances change and you are no longer in a position to answer 'No' to all yes/no questions below.

For children under 18, this form should be filled by a parent.

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Name of Particpant *
Phone Number for Contact Tracing *
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *
Have you been in close contact with a confirmed or suspected case of COVID-19 in the last 14 days? *
Do you have 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 visited any of the countries outside Ireland excluding Northern Ireland and green-list locations on the list at in the last 14 days ? *
Have you been advised by a Doctor or the HSE to self-isolate at this time? *
Have you been advised by a Doctor or the HSE to cocoon at this time? *
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 my personal information given by me above including my name and contact details may be shared with the Health Service Executive (HSE) for the sole purpose of contact tracing in line with public health guidelines only if requested. I agree to verbally affirm these answers before attendence at each event at the Club and inform the club of any change.  I agree the information may be kept on file for a minimum of two weeks and until the end of this year, if required. *
Required
Agreed by (type your name to affirm agreement).  Parent/Guardian to agree for children under 18. *
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