COVID SCREEN

Please complete the following screening for each member of your family that is attending Fresh Start programming:

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1. Do you hve any of the following symptoms?
2. Have you traveled internationally within the last 14 days (outside Canada)?
3. Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
4. Have you had close contact with a person with acute respiratory illness who has been outside Canada in the last 14 days?
5. Have you had contact with anyone in self-isolation in the past 14 days?

To be signed by guardian or parent if participant is under the age of 16 years of age.

Your Signature

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