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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)?:
Fever
New, persistent, dry cough
Shortness of breath
Loss of taste or smell
Diarrhoea or vomiting
Muscle aches not related to sport/training
I have had none of the above symptoms
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):
NO
YES
If ‘Yes’, please provide details:
Do you have any underlying medical conditions?(example: chronic respiratory, asthma, heart, kidney, liver, neurological, diabetes, immune system):
NO
YES
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?:
NO
YES
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?:
Yes I understand and accept the risks associated with returning to train
No I do not accept the risks
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
Submit