Covid-19 Daily Health Screen Form

Date

Name

Email Address

Aquatic Programs

Which programs are you attending? Required

Private Swim Lesson at Snug Point Pool

TBCA Member Swim Lessons

TBCA Member Aqua Fit

Open Water Program

Travel History

Have you or anyone in your household travelled outside of Canada in the past 14 days? Required

Yes

No

Covid-19

In the last 14 days, have you had contact with someone who has had symptoms such as cough and/or fever, or been diagnosed with Covid-19? Required

Yes

No

Symptoms Check

Have you or anyone in your household experienced any of the following symptoms in the last 14 days? Required

Fever/Temperature above 104F

Cough and/or sore throat

Respiratory illness and/or difficulty breathing?

I have experienced NO symptoms

Symptom Declaration

I will inform 947 Swim if I or any member of my family experience any symptoms Coronavirus-Covid-19

Parent/Caregiver Responsibility

I agree that if my child(ren) are under the age of 8 years old and/or are unable to swim on their own, I will remain within arms reach during the entire lesson with 947 Swim, and will follow all pool rules and procedures set out by facility operators and 947 Swim

No Refund Policy

I agree that any false information declared on this form, or failure to follow the policies and procedures set out by 947 Swim and Facility Operators will result in cancellations of my lessons or classes with a No Refund penalty