Kuruka Covid Screening - To be done prior to arrival

This survey must be completed before arriving at Kuruka Equestrian by every person entering the barn

If you answer YES to any of the questions you must stay home and not attend lessons/enter Kuruka Equestrian.

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* 1. Name of participant

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* 2. Date

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* 3. Have you traveled outside of Canada in the last 14 days?

Yes

No

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* 4. Have you, your child or anyone in your household had any of the following symptoms currently or within the last 14 days?
Fever (>37.8 C), Chills, cough that's NEW or worsening, cough , shortness of breath (out of breath, unable to breathe deeply), sore throat, difficulty swallowing, hoarse voice (more rough or harsh than normal), runny nose, stuffy or congested nose, lost sense of taste or smell, headache, digestive issues (nausea/vomiting, diarrhea,
stomach pain), fatigue (lack of energy, tiredness), falling down more than usual, for young children: sluggishness or lack of appetite Fever, cough, difficulty breathing, runny nose, headache

Yes

No

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* 5. Have you, your child or member of your household been diagnosed with COVID 19, been identified as close contact of a confirmed case of COVID19 or are you, you child or someone you are in contact with currently been tested and awaiting results for COVID19 within last 14 days?

Yes

No

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* 6. eSignature
Please indicate your full name as paticipant (18+) or as the custodial parent and/or guardian of the child.