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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 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): Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have
  • Shortness of breath: 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
  • (For adults > 18 years or older) Fatigue. lethargy, malaise and/or myalgias:  Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have) If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, answer “No".
  • (For children < 18 years) Nausea, vomiting and/or diarrhea: Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have


​2. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)? 

3. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing. 

4. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized* or have tested positive for COVID-19 in the last 90 days and since been cleared), answer “No.”

5. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?If you have already gone for a test and got a negative result, answer "No." If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, answer "No." 

6. In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit? If you have since tested negative on a lab-based PCR test, answer “No.”

7. In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements) in the last 14 days?If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, answer “No.” 

8. In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate in the last 10 days? If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, answer “No.” 

9. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, answer “No.” If you are fully vaccinated or have tested positive for COVID-19 in the last 90 days and since been cleared, answer “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/

COVID-19 MEMBER SCREENING NOVEMBER 2021 - 2022

First Member's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Member'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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