BEAUMONT DAILY SCREENING FORM

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Based on how the individual (or guardian) answers the questions, your swimmer MAY NOT be permitted to participate in the swim activity as per AHS guidelines. Children/youth must have a parent complete this screening tool. Please complete the form WITHIN 2 HOURS of your practice, PRIOR to attending the event or practice each day.

Practice Date: *

YYYY

Please enter the name of your swimmer (First, Last): *

Which group is your swimmer in? *

(Group 1)

(Group 2)

(Group 3)

Novice 2 Group A

Novice 1 Group A

Novice 1 Group B

Is the participant experiencing any of the following symptoms: Fever, Cough, Shortness of Breath, Loss of Sense of Smell or Taste, Chills, Sore Throat (Painful Swallowing), Runny Nose, Congestion, Nausea, Vomiting, Diarrhea, Loss of Appetite, Feeling Unwell/Fatigued, Muscle/Joint Ache, Headache, or Conjunctivitis (Pink Eye)? *

Yes

Has the participant travelled outside of Canada within the last 14 days? *

Yes

Has the participant had close contact with a case of COVID-19 in the last 14 days? *

Yes

If the participant answered YES to any of the above questions they MUST not attend swimming. Use the AHS Online Assessment tool or call Health Link 811 for further detail and to determine if testing is recommended.

Parent / Guardian Name *

First Name Last Name

Acknowledgement: I understand, acknowledge and agree this checklist and all its terms apply to and bind me, irrespective of my status as a participant in Triton Swim Club member such that no liability or fault can be attributed to anyone other than myself for any accidents or transmission whatsoever. Please sign by entering your EMAIL ADDRESS below: *

Email Address

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