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Toy Heaven COVID-19. Questionnaire

The safety of our staff, suppliers, customers and families remains our priority. As Covid-19 continues to evolve and spread, we are monitoring the situation closely and will periodically update our policies based on current recommendations from Leeds, Grenville and Lanark District Health Unit.

To prevent the spread of Covid-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.

Date: November 26, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Self Declaration by Virtual Reality Participant/Visitor

1. Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, loss of smell or taste, loss of appetite, chills, etc)*
No
Yes
2. Have you travelled outside of Canada in the past 14 days?*
No
Yes
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed)?*
No
Yes

If the answer is "yes" to any of the questions, access to Virtual Reality will be denied.

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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