COVID-19 Self-Assessment Form
A separate form is required for each person entering the gym for class. Ex. one form per student and per parent/guardian in a Tall & Small class.
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Email *
Student/participant's Name: *
Program: *
Symptoms
- Fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher)
- Chills
- Cough that is new or worsening (continuous, more than usual)
- Barking cough, making a whistling noise when breathing (croup)
- Shortness of breath (out of breath, unable to breathe deeply)
- Sore throat
- Difficulty swallowing
- Runny nose (not related to seasonal allergies or other known causes or conditions)
- Lost sense of taste or smell
- Pink eye (conjunctivitis)
- Headache that’s unusual or long lasting
- Digestive issues (nausea/vomiting, diarrhea, stomach pain)
- Muscle aches (not sport related)
- Extreme tiredness that is unusual (fatigue, lack of energy)
- Falling down often
- For young children and infants: sluggishness or lack of appetite
Is the student/participant exhibiting any of these symptoms? *
Has a doctor, health care provider, or public health unit said the student/participant should be currently isolating (staying at home)? *
A copy of your responses will be emailed to the address you provided.
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