BTC Return to Play COVID-19 Health Screening - Juniors
The purpose of this screen is to inform and make you aware of the risks involved in returning to train
Parent's Name
*
First Name
Last Name
Email
*
example@example.com
Child Name
*
First Name
Last Name
Has your son/daughter had confirmed COVID-19 infection or any symptoms (listed below) in keeping with COVID-19 in the last five months? 1/ Fever 2/ Persistent, dry cough 3/ Loss of taste or smell
*
Yes
No
If Yes then provide details
Has your son/daughter had any known exposure to anyone with confirmed or suspected COVID-19 in the last two weeks? (e.g. close contact, household member)
*
Yes
No
If Yes then provide details
Does your son/daughter have any underlying medical conditions? (Examples include: respiratory conditions including asthma; heart, kidney, liver or neurological conditions; diabetes mellitus; a spleen or immune system condition; currently taking medicines that affect your immune system such as steroid tablets)
*
Yes
No
If Yes then provide details
Does your son/daughter live with or will knowingly come into close contact with someone who is currently ‘shielding’ or otherwise medically vulnerable if they return to the training environment?
*
Yes
No
If Yes then provide details
Are you able to train
*
Yes
No
Have you sought medical advice?
*
Yes
No
Signature
*
All information collected will be used and stored in accordance with the Club's GDPR Policy.
Submit
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