Health Questionnaire and Contact List


Trip Leaders / Instructors / Event Organizers: Please print out this questionnaire as part of your "day of" preparation. Keep the completed form for your records.

Participants: For the health and safety of club members, if you answer yes to any question, please do not facilitate or participate in this activity. 

  1. Do you have a fever (>37.8°C or >100°F)?
  2. Do you have any cold/coronavirus symptoms: cough, sneezing, congestion, sore throat or difficulty swallowing?
  3. Are you having difficulty breathing or shortness of breath?
  4. Have you travelled outside the province of BC within the last 14 days? If yes, where?
  5. Have you been in contact with anyone who has travelled outside the province within the last 14 days?
  6. Have you been in contact with someone who has COVID-19 symptoms or has been quarantined within the last 14 days?

If during the trip, or after returning home and within 14 days, you develop symptoms of COVID-19 (and/or test positive for SARS-CoV-2) or have been advised to quarantine or seek medical attention please contact the leader of the activity so they may advise the other participants.

By signing I confirm that I have answered "no" to the above questions regarding COVID-19.
Name: Contact Phone: Signature:
(Leader)    
     
     
     
     
     

Additional participants (i.e. Social event, 2nd pod)

(Leader)