Health Survey

Name of Member:*

Contact phone number:*

Have you had confirmed Covid-19 infection or any symptoms in keeping with Covid-19 in the last five months (tick any that may apply)?:

If you have had any of the above symptoms you may provide further information here:

Have you had a known exposure to anyone with confirmed or suspected Covid-19 in the last two weeks? (e.g. close contact, household member):

If ‘Yes’, please provide details:

Do you have any underlying medical conditions?(example: chronic respiratory, asthma, heart, kidney, liver, neurological, diabetes, immune system):

If ‘Yes’, please provide details of your medication or condition:

Do you live with or will you knowingly come in to close contact with someone who is currently ‘shielding’ or otherwise medically vulnerable?:

If ‘Yes’, please provide details and tell us how you may minimise any risk:

Do you fully understand the information presented in the COVID Return To Training briefing and the risks in relation to the COVID 19 pandemic?:

Please confirm the following with relation to travel abroad:

I have not travelled abroad in the last 14 days
If I travel abroad in the future, I agree to keeping Dove Valley ASC informed
Upon returning from abroad I will follow government guidance and self isolate if required

Please confirm the following declaration as a true submission to the best of your knowledge:

I am the member named and I am over 18 years of age
I am declaring as a parent/guardian of the named member who is under the age of 18
I agree to the terms and conditions sent out in the risk assessment which can be found on this website