Planet Gymnastics Pickering COVID-19 Student Screening Questionnaire

Planet Gymnastics Pickering COVID-19 Student Screening Questionnaire

Please fill out this form and submit it to the gym before your arrival.
Upon entering Planet Gymnastics, any workers or visitors accessing the facility MUST
complete a health questionnaire or this online form. The purpose of the questionnaire is to verify that they are free (to the best of their knowledge) of COVID-19 symptoms, as well as other related restrictions in accordance with Public Health Ontario recommendations.
The following will be implemented upon entering Planet Gymnastics:
1. Health questionnaire or Confirmation or online form.
2. Signage informing all of the safety/sanitization process
3. Alcohol based hand sanitizers available at screening table and in all common areas

You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT enter the Facility.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional and Ontario Public Health.

1) Have you had any of the following symptoms in the last 24 hours? *

	Yes	No
Fever (usually 38.0 Celsius or Higher), Cough, Shortness of breath of difficulty breathing, Sore Throat, Headache

If you answered “Yes” to question one, please DO NOT enter the facility. You should:
- Self- quarantine for at least 10 days from the date on which you first experienced any of the above symptoms ; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)
- Contact Public Health.

2) In the last 14 days have you: *

	Yes	No
Been in contact with someone who was diagnosed with COVID-19? Been in close contact with someone who had COVID-19 symptoms? Been tested personally for Covid-19?

If you answered “Yes” to any part of question two, please DO NOT enter the facility. You should self quarantine for at least 14 days.

I certify to the best of my knowledge; this information is accurate.

By entering this facility, you are aware that you agree to fully accept all known and unknown risks, including the potential risk of exposure to respiratory illnesses such as the corona virus (COVID-19). The corona virus is primarily transmitted via exhaled respiratory droplets, most often through coughing and sneezing. These droplets can travel up to six feet and are more commonly transmitted between persons rather than from equipment to persons. Although we regularly sanitize our equipment and presently are using enhanced cleaning methods and enforcing social distancing in our facility, you understand that you may be exposed to the corona virus or its symptoms through no fault of our own. Known corona virus symptoms include fever, coughing, shortness of breath, pneumonia, kidney failure, and may include other symptoms, stroke or even death (collectively "Symptoms"). You understand and agree that you will hold us harmless and you will not hold us liable for any real or perceived Symptoms of COVID-19 or any other disease, illness, or condition, nor for exacerbating any existing symptoms, and you fully agree to accept all risks of entering the facility, using the equipment, working with personal trainers, attending classes, and/or interacting or being exposed to other members.
Signature *

Clear
1st Child's / Parent / Visitor Name *

First Name Last Name
Age of Child / Parent / Visitor
2nd Child's / Parent / Visitor Name ( If Applicable )

First Name Last Name
Age of Child / Parent / Visitor
3rd Child's / Parent / Visitor Name ( If Applicable )

First Name Last Name
Age of Child / Parent / Visitor
4th Child's / Parent / Visitor Name ( If Applicable )

First Name Last Name
Age of Child / Parent / Visitor
Date of Class *

Month Day Year
Date
Time of Class

: Hour Minutes AM/PM Option
Should be Empty: