COVID-19 Health Questionnaire

I will be attending the following event(required)

Student's Name(required)

Email(required)

Emergency Contact Name and Phone Number(required)

Has anyone in your household received a positive COVID-19 test result in the past 14 days?(required) Yes

No

Are you or anyone in your household waiting for the results of a COVID-19 test?(required) Yes

No

Have you or anyone in your household developed any of the following in the past week? (required) A new continuous cough

A high temperature

A loss of, or change in, your normal sense of smell

None of the above

Have you or anyone in your household been contacted by NHS Test and Trace in the past 10 days and been advised to isolate?(required) Yes

No

I acknowledge that as part of the Club's COVID-19 procedures my temperature will be taken before entering the venue.(required) I agree to accept the results of this reading

Person completing this form

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