Covid-19 Questionnaire

Fever *

Yes

No

Cough *

Yes

No

Shortness of Breath / Difficulty Breathing *

Yes

No

Sore Throat *

Yes

No

Chills *

Yes

No

Painful Swallowing *

Yes

No

Runny Nose / Nasal Congestion *

Yes

No

Feeling Unwell / Fatigued *

Yes

No

Nausea / Vomiting / Diarrhea *

Yes

No

Unexplained Loss of Appetite *

Yes

No

Loss of Sense of Taste or Smell *

Yes

No

Muscle / Joint Aches *

Yes

No

Headache *

Yes

No

Conjunctivitis *

Yes

No

Have you, or anyone in your household, travelled outside of Canada in the last 14 days? *

Yes

No

Have you or your child(ren) attending the program had close unprotected* contact (face-to-face contact within 2 metres/6 feet) with someone who is ill with cough and/or fever? *

Yes

No

Have you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19? *

Yes

No

I certify that I am not experiencing any of the symptoms of COVID-19 and will notify No More Excuses Inc. of any change in my personal health. *

I waive any right to claim against No More Excuses Inc., for any bodily injury, loss, or damage as a result of any exposure to COVID-19. *

Yes

I understand that by submitting this waiver, this may affect my legal rights. *

Yes

Name *

First Name

Last Name

Date *

Enter Today's Date

MM

DD

YYYY