COVID-19 Health Declaration

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat. And I do not have any family member in the household experiencing the following symptons or signs. New or Worseining cough - Pink eye - Shortness of breath - Sore throat - Running nose, Sneezing, or nasal congestions (excluding seasonal allergies) - Hoarse Voice - Difficulty swallowing - New Smell or Taste Disorder - Nausea / Vomiting - Diarrhea, abdominal pain - Unexplained Fatigue, Chills or Headache)

I haven’t been in close contact with a Covid-19 patient in the last 14 days. And I do not have any family members travelled outside of Canada, including the United States, or have had close contact with anyone that has travelled outside of Canada within the last 14 days.

I do not have any member in the household had close contact with anyone with respiratory illness or confirmed or probable case of COVID-19

Initials

Date

I have Read and Agree to the TKFW Assumption of risk & release liability Waiver Covid-19 below. And I declare that the info I’ve provided is accurate & complete

TKFW Assumption of risk & release liability waiver COVID-19

Thanks for submitting it!