ASC Junior COVID19 Pre-Screening Health Check
Please complete the following questionnaire, answering all questions Yes/No prior to travelling to the Athlone Sports Centre. This process must be completed for each and every session with your club, that you intend to attend. If you answer Yes to any of the questions, please notify the Club Covid19 Officer by phone. You should not leave home and you should not travel to the pool. You should await further information.
Name
*
First Name
Last Name
Phone Number
*
Date of Session
*
-
Day
-
Month
Year
Date
Have you travelled to any country (outside of all Ireland) in the last 14 days?:
*
YES
NO
Have you been in contact with a case of COVID19 (>15mins face to face contact)?
*
YES
NO
Have you been contacted by a member of Public Health about a recent case of Covid-19?
*
YES
NO
Did you have any of the symptoms below in the last 48 hours : Cough, Fever, Feeling short of breath, Excessive fatigue/tiredness (out of proportion to normal), headache, sore throat, general aches and pains (out of proportion to normal)
*
YES
NO
Signature (if you are U18, it should be signed by parent/guardian)
*
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