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COVID-19 Screening Questionnaire 

COVID-19 SCREENING QUESTIONNAIRE

The safety of our Members, Guests 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 and Guests to complete this questionnaire prior to arriving at the Club.

PLEASE ASK YOURSELF THE FOLLOWING QUESTIONS EACH DAY BEFORE COMING TO THE CLUB: 

1. Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.

  • Fever and/or chills: Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
  • Cough or barking cough (croup): Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have) 
  • Shortness of breath: Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)
  • Decrease or loss of smell or taste: Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
  • Muscle aches/joint pain: Unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)
  • Extreme tiredness: Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have) 
  • Sore throat: Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)
  • Runny or stuffy/congested nose: Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have
  • Headache: New, unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)
  • Nausea, vomiting and/or diarrhea: Not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have


​2. In the last 10 days, has someone you live with: been sick with symptoms associated with COVID-19?  and/or  tested positive for COVID-19 (on a rapid antigen test or PCR test)?

3. In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?

4. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?

5. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)?

If public health has advised you that you do not need to self-isolate, select “No.”

6. In the last 14 days, have you travelled outside of Canada? If exempt from federal quarantine requirements as directed by the border agent at your point of entry (for example, you have two or more doses of a COVID-19 vaccine and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select “No.”

 * A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e., Johnson and Johnson).

PLEASE DO NOT COME TO THE CLUB IF YOU ANSWER YES TO ANY OF THE ABOVE QUESTIONS AND COMPLETE THE ONTARIO COVID-19 ASSESSMENT THROUGH THE FOLLOWING LINK: 

https://covid-19.ontario.ca/screening/customer/





First Guest's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Guest'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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