Participant - Covid-19 Pre-screen

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Participant - Covid-19 Pre-screen - Pool

*Required

What date is the participant attending the aquatics activity? *

YYYY

What is the name of the participant? *

I acknowledge that the following information is serious, and that my responses will be truthful for the safety of the others: *

Yes

Required

Has the participant experienced any of the following issues/symptoms: *

Fever

Cough

Shortness of Breath

Runny nose

Sore Throat

Chills

Painful swallowing

Nasal Congestion

Feeling unwell/ fatigued

Nausea / vomiting / diarrhea

Unexplained loss of appetite

Loss of sense of taste or smell

Muscle / Joint aches

Headache

Conjunctivitis (commonly known as pink eye)

No Symptoms

Required

In the last 14 days, have you or your family been in physical contact with someone who has tested positive for COVID-19?

Yes

Yes - we are living in the same home as someone who has tested positive

In the last 14 days, have you or your family been in close contact with a person who (please check all that apply): *

Is currently sick with a new cough, fever, or is having difficulty breathing?

Has returned home from outside of Canada in the last 2 weeks?

Has shown various symptoms of COVID-19?

None of the above

Have you or your family traveled outside of Canada in the past 14 days? *

Yes

Does the participant understand the importance of physical distancing?

Yes

Clear selection

If you agree that all of the above statements are true, please check here:

I agree

I disagree

Submit

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