Covid-19 Screening Form is paused until further notice

Please fill out this mandatory COVID-19 screening form before attending our programs. Your response will be recorded and assessed by our team, so please ensure your information is accurate.

You will be required to fill out a digital signature at the bottom of this form which affirms that your answers are true and complete to the best of your knowledge.

First Name

Last Name

Phone

Have you travelled outside Canada in the past 14 days?

Yes No

Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes No

Do you currently have any of the following symptoms:

Fever
New onset of cough or worsening chronic cough
Shortness of breath or difficulty breathing
Sore throat or difficulty swallowing
Headaches
Chills
Decrease or loss of taste/smell
Unexplained fatigue, malaise, muscle aches (myalgias)
Runny nose/nasal congestion without other known cause
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)

Yes No

Member Signature

Acceptance

By typing your name in the "Member Signature" space above and clicking the box beside this statement, you certify that your answers are true and complete to the best of your knowledge.