STRAWHOUSE
COVID-19: Self-Assessment Form
Name
*
First Name
Last Name
Email
*
Contact Phone Number
*
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
What is the date of your next visit to Strawhouse?
*
-
Day
-
Month
Year
Date
In the last 10 days have you experienced any of the following symptoms - high temperature, new & continuous cough, loss or change to your sense of smell or taste?
*
Yes / No
In the last 10 days, have you been within 2 metres of someone with a confirmed or suspected case of COVID-19?
*
Yes / No
I hereby confirm that the information I provide in this form is true to the best of my knowledge, and that I have read and will comply with Strawhouse Studio’s COVID-19 policy, as detailed on its website.
*
Yes I agree / No I do not agree
Submit
Should be Empty: