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Member Health Attestation - COVID-19 Screening Questionnaire 

COVID-19 MEMBER SCREENING QUESTIONNAIRE

The safety of our Members and Employees is our top priority. In order to prevent the spread of COVID-19 and reduce the potential risk of exposure to our Membership, we are asking all Members to complete this questionnaire prior to arriving at the club.

Please ask yourself the following questions before arriving for the day.

Your participation is important to help us take precautionary measures to protect you and your fellow Members.

1.    Are you currently experiencing any of the following symptoms?

▪       Fever (100.4 F/ 37.8 C or greater measured by an oral thermometer) - YES/NO

▪       Cough - YES/NO

▪       Shortness of breath or difficulty breathing - YES/NO

▪       Sore throat - YES/NO

▪       New loss of taste and/or smell - YES/NO

▪       Chills - YES/NO

▪       Head or muscle aches - YES/NO

▪       Nausea, diarrea, vomiting - YES/NO

2.   In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms since your contact with them? - YES/NO

3.   In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? - YES/NO

4.   Have you been tested for COVID-19 and are awaiting to receive your results? - YES/NO

5.   Have you tested positive for COVID-19, or presumed positive for COVID-19 based on your health care providers assessment of your symptoms? - YES/NO

6.   In the past 14 days, have you travelled outside Canada? - YES/NO

7. In the past 14 days, have you been in close proximity to anyone who has travelled outside Canada? - YES/NO

Members who answer yes to one or more of these questions are asked to complete the Ontario COVID Assessment prior to coming to the club,

PLEASE DO NOT COME TO THE CLUB IF YOU ANSWER YES TO ANY OF THE ABOVE QUESTIONS

 

https://covid-19.ontario.ca/self-assessment/

COVID-19 MEMBER SCREENING NOVEMBER 2020

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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*
Parent or Guardian's Date of Birth*
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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