CLUB ACTIVE INFORMATION QUESTIONNAIRE:
Name
First Name
Last Name
E-mail
Phone Number
-
Phone Number
Type a question
YES
NO
1. Have you returned to the Island of Ireland from another country in the last 14 days ?
2. Have you been in close contact with anyone who has been confirmed with having the COVID 19 virus?
3. Do you live in the same house hold as a person who has symptoms of COVID 19 and who has been in isolation during the last 14 days?
4. Do you have any of the following typical symptoms of COVID 19:
-FEVER
-HIGH TEMPERATURE
- PERSISTANT COUGHING OR BREATHING DIFFICULTIES/ SHORTNESS OF BREATH
Signature
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