Laois Marlins Covid-19 Self Assessment

Laois Marlins Covid-19 Self Assessment
Squad *
Senior Swimmers Name

First Name Last Name
Senior Development Swimmers Name

First Name Last Name
Junior Swimmers Name

First Name Last Name
Star Swimmers Name

First Name Last Name
Parent On Duty

First Name Last Name
Coach Name

First Name Last Name
Masters Name

First Name Last Name
Senior Swim Session Date

Day Month Year
Date
Senior Development Swim Session Date

Day Month Year
Date
Masters Swim Session Date

Day Month Year
Date
Junior Development Swim Session Date

Day Month Year
Date
Stars Swim Session Date

Day Month Year
Date
Parent On Duty Swim Session Date

Day Month Year
Date
Coach Date

Day Month Year
Date
Have you traveled to any country (outside of all-Ireland) in the last 14 days? *

Yes No
Have you been in contact with a case of COVID-19 (>15 minutes 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
Symptoms
- Cough
- Fever
- Feeling short of breath
- Excessive fatigue/tiredness (out of proportion to normal)
- Sore throat
- Headache
- General aches and pain (out of proportion to normal)
- Loss of taste or smell
- Gastrointestinal issues (e.g. Diarrhea, Nausea, etc.)
Do you have any of the symptoms above in the last 48 hours? *

Yes No
Guardian *

First Name Last Name
As you have selected Yes to one of the questions you must not come to any club activities and you should seek advice from a GP
As you have selected No to all questions you can attend training.
Should be Empty: