Covid-19 Child Questionnaire North Dublin

Camp Location your child is attending*

Start date of camp*

Name of child*

Name of Parent*

Age of child*

Contact Number*

Questionnaire

Before your child can participate in our activities we need you to complete the following questionnaire regarding your child. This is being done in order to protect our employees and other children in the activity. Your co-operation and support are appreciated. Your child may not be admitted if you answer ‘YES’ to any questions.

1. Has your child symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days?*

Yes
No

2. Have they been diagnosed with a confirmed or suspected COVID-19 infection in the last 14 days?*

Yes
No

3. Are they in close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day)?*

Yes
No

4. Have you been advised by a doctor to isolate your child at this time?*

Yes
No

5. Are any other circumstances relating to COVID-19, not included in this form, which may need to be disclosed to allow your child’s participation in the activity.*

Yes
No

6. Do you give permission for your child to use hand sanitiser when required?*

Yes
No

Covid-19 Child Questionnaire North Dublin

Covid-19 Child Questionnaire North Dublin

Questionnaire

This form must be completed before your child will be allowed entry into our camp