Mallow - Miriam & Dawn's Groups CDYS Covid

Mallow (Miriam & Dawn) - Cloyne Diocesan Youth Services

Covid - 19 Health Assessment
This Form MUST be completed by All Young People & their Parent/Guardian who are attending any group within CDYS. IF you are attending several Groups within the week you will need to complete this form for EACH group. The form must be submitted 12-24 hour's before the group commences.

Failure to complete this form before attending will result in you not being able to gain access to any CDYS facility.
Parent/Guardian Name (Must be completed by Adult if Young Person is under 18) *

First Name Last Name
Parent/Guardian Telephone Number *
Please enter a valid phone number.
Young Adults Name *

First Name Last Name
Date of Birth of Young Adult *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

Town County

Eircode
1. Do you have symptoms of cough, fever, high temperature (Higher than 37.5), sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days? *
2. Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *
3. Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days *
4. Have you been advised by a doctor to self-isolate at this time? *
5. Have you returned from traveling in the past 14 days? *
Which Group are you attending?
If you have answered YES to any of the above questions you MUST self Isolate & Contact your GP. You must NOT attend any CDYS Facility.
Should be Empty:

Mallow (Miriam & Dawn) - Cloyne Diocesan Youth Services