Covid 19

/>

Covid - 19 Screening Form

* Indicates required field

Parent Name: *

First

Last

Athlete Name: *

Phone Number *

Have you been in contact with a confirmed case of Covid-19 within the last 14 days? *

Yes No

Has anyone in your household tested positive for Covid-19 within the last 2 weeks? *

Yes No

Have you been contacted by the HSE contact tracing team? *

Yes No

Have you been practicing social distancing? *

Yes No

Please tick below if you have any of the following symptoms: *

Persistent Dry Cough Fever above 38 degrees Fatigue Sore Throat Loss of taste or smell Difficulty Breathing A combination of the above

Is there any issues we should be aware of? *

Submit

Unit 4-6 Merlin Park Ind Est Doughiska, H91HN76 Privacy Welfare Rules Covid-19 Coaches Stuntworx Elite /// 091 771 765 /// info@stuntworxelite.com