Covid 19 Self Declaration

Please carefully read and answer the questions below for the safety of yourself and other class participants. Anyone attending a class must complete this form prior to arrival.

First Name

Last Name

Within the last 14 days, have you received a confirmed diagnosis for coronavirus (COVID-19) by a coronavirus (COVID-19) test or from a diagnosis by a health care professional or are you waiting for a pending COVID-19 test result?

Yes

In the last 14 days, have you had close contact with or cared for someone diagnosed with COVID-19 or are you participating in a COVID-19 clinical study that includes being exposed to the virus?

Yes

In the last 14 days, have you experienced any cold or flu-like symptoms (to include fever, cough, shortness of breath or difficulty breathing, sore throat, pressure in the chest, extreme fatigue earache, persistent headache, diarrhoea, vomiting, muscle pains, chills, repeated shaking with chills and persistent loss of smell or taste)?

Yes

I confirm that the information given in this form is true. I understand that if I have answered yes to any of the above questions I will not be allowed entry to the class. I understand that if my answers to any of the above questions change prior to attending I must inform the instructor and must not attend the class.

Date

Initials

Thank you for completing the form