Daily Academy COVID-19 Screening Questionnaire

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First Name of Student *

Last Name of Student *

Class Level *

Future Stars

Bronze

Silver

Gold

Elite

Performance Program

Please select the day of your child's class *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Please enter the time of your child's class *

Please provide your phone number. *

Does your child have any of the following symptoms: fever and/or chills, sore throat or difficulty swallowing, new or existing cough, barking cough, difficulty breathing, decrease or loss of taste or smell, runny or stuffy nose, headache, nausea, vomiting and/or diarrhea, extreme tiredness or muscle aches? *

Yes

Has your child travelled Internationally within the last 14 days (outside Canada)? *

Yes

Has your child had a close contact with a confirmed or probable case of COVID-19? *

Yes

Has your child had close contact with a person with acute respiratory illness who has been outside Canada in the last 14 days? *

Yes

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

Yes

Please verify the following: *

I understand that if I have answered yes to any of these questions, my child should not be attending classes until cleared by their doctor or Public Health.

Please enter your full name, acknowledging that you have read and agree to the above. *

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