Clifden Music Hub - Covid -19 Health Questionnaire

Covid -19 Health Questionnaire

We are asking parents/guardians to complete this form at home and submit each morning of the hub to save time and avoid queuing in the venue or delays to the start of the hub. Please make sure you are also checking participants for symptoms prior to entering the venue in case they become ill after submitting the form. The form should be submitted on the day of attendance and not the night before.
Participant Name:*

First NameLast Name
Parent/Guardian Name:*

First NameLast Name
Do you believe that the participant may currently have COVID-19?*

YesNo

Has the participant had any of the following symptoms of COVID-19 in the past 14 days?*

	No	Yes
High temperature (i.e. over 37.5°c)
A new continuous cough
New unexplained shortness of breath
Loss of sense of smell, of taste or distortion of taste

If you have answered YES to any of these questions the participant should stay at home and you should contact your GP by phone for further advice.
If you have answered NO to all of the above questions the participants may attend our Music Hub.

Please (digitally) sign this form to confirm
- that the details above are true to the best of your knowledge
- that you are the parent/guardian of the person named above
- that you understand the risks involved in participation and the participant is participating on a voluntary basis and so may opt-out at any time.
Signature*

Clear
I understand and confirm
Should be Empty: