Health Questionnaire and Contact List

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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, you are required to be fully vaccinated against COVID-19 to attend this event. Also 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 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 am fully vaccinated against COVID-19 and have answered "no" to the above questions regarding COVID-19.
Name (Leaders, Participants) Contact Phone Your Signature
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