Language
English (Canada)
ABRA Covid-19 Health Assessment:
Date
*
-
Year
-
Month
Day
AM
PM
AM/PM Option
Last Name
*
Address
*
Street Address
State / Province
Phone Number
*
E-mail
example@example.com
Have you or anyone in your household travelled outside of Canada in the past 14 days?
*
Yes
No
Have you or anyone in your household tested positive for Covid-19 in the past 14 days?
*
Yes
No
Are any members of your household currently experiencing any of the following symptoms: fever above 38 degrees Celsius, cough, shortness of breath/difficulty breathing, sore throat, runny nose?
*
Yes
No
Do you understand and consent to the terms outlined in the COVID-19 lake use information sheet (https://bit.ly/2XZiIwO)?
*
I agree
I disagree
Guest names (If applicable) leave blank if bringing no guests*
INCLUDE FULL NAMES
Guest community
Which community are your guest(s) from?
*Maximum of 2 guests per household. Children who are mobile (i.e., crawling) count as guests.
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