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 (within 6 feet for more than 15 minutes) with anyone that has tested positive for COVID-19 ?
4. Have you had close contact (within 6 feet for more than 15 minutes) with someone that has COVID-19 like symptoms in the last 14 days?
5. Have you had contact with anyone in self-isolation or awaiting the results of a COVID-19 test in the past 14 days?

Your Signature (To be signed by the legal guardian if screen was completed by someone less than 16 years of age)

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