COVID-19 Disclosure Form

Are you experiencing any of the following?

Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)

Severe chest pain

Having a very hard time waking up

Feeling confused

Loosing consciousness

None of the above

Are you experiencing any of the following?

Mild to moderate shortness of breath

Inability to lie down because of difficulty breathing

Chronic health conditions that you are having difficulty managing because of difficulty breathing

None of the above

Are you experiencing any of the following?

Have you travelled to any countries outside Canada (including the United States) within the last 14 days?

Yes

No

Within the last 14 days did you provide care or have close contact with a symptomatic person known or supspected to have COVID-19?

Yes

No

Did you have close contact with a person who travelled outside of Canada in the last 14 days who has become ill (fever, cough, sore throat, runny nose, or headache) ?

Yes

No

Do you agree to wear a mask (surgical, cotton/polyester 2 ply or greater) as directed by public health, at all times during in-door training?

Yes

No

We care about your safety

COVID-19 Disclosure

Thank You,

From all the staff at PUSH for Life.

We look forward to training with you.