GVOC Wednesday Evening Training at Jericho Covid-19 Screening

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All participants are required to complete this form. If a parent/guardian is filling in the form for their child, please fill in your name first, and then add the child's name when prompted.

Email *

First Name *

Last Name *

Child's name (first, then last) if a parent is doing the form for their child who is participating.

Are you experiencing any of the following: *

Difficulty breathing

Fever or chills

New or worsening cough

Sore throat

Loss of sense of smell or taste

Headache

Extreme fatigue or tiredness

Diarrhea

Loss of appetite

Nausea or vomiting

Body aches

None of the above

Required

Do any of these lifestyle situations apply to you? *

Live with someone who has had any of the above symptoms in the last 14 days?

Travelled outside of Canada (including to the USA) in the past 14 days?

Been in contact with anyone confirmed or expected of Covid-19 in the last 14 days?

No to all

Required

Today's date - by clicking this box, it represents your signature. *

YYYY

A copy of your responses will be emailed to the address you provided.

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