Gymalaya Burlington COVID-19 Screening Assessment

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*NOTE* When signing this form, you are asserting that the information is true and that you have personal knowledge of the facts contained in the form. By signing, you are also stating that you are competent to and that you are of sound mind.

Email *

Full name *

Your child name *

If you or your child have any ONE of the following symptoms listed below, DO NOT COME TO CLASS and seek medical advice. *

Fever and/or chills; Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup)

Shortness of breath

Decrease or loss of taste or smell

Sore throat or difficulty swallowing

Nausea, vomiting, and/or diarrhea

Extreme tiredness or muscle aches

None of the above

Required

In the last 14 days, has your child travelled outside of Canada? *

Yes; Stay at home for 14 days after returning from travel. Check for symptoms

Has a doctor, health care provider, or public health unit told you that you or your child should currently be isolating (staying at home)? *

Yes; Do not go camp. Follow directions or health care professionals

In the last 14 days, have you or your child been identified as a “close contact” of someone who currently has COVID-19? *

Yes; Stay at home for 14 days or as directed by public health. Check for symptoms

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *

Yes; Do not go to school or child-care. Follow directions of public health officials

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If the person got a COVID-19 vaccine in the last 48 hours and is experiencing a mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” *

Yes; Do not go to school or child-care. Follow directions of public health officials

Thank you for completing the assessment form!

Please visit halton.ca/COVID19 for information on ways to protect yourself, your family and your community. Stay Safe and Take Care!
Gymalaya Burlington Team

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