Form Builder

Recreation Facility COVID-19 Screening

As part of our commitment to providing a safe and healthy community, this recreation facility screening is required for entrance to the facility. Your answers will be used to generate a pass/fail response, which may be shared with the Township of Wellesley. Thank you for providing honest answers. Together, we are doing our part to ensure a safe community and minimize the spread of COVID-19.

Enter Participants Name

Participants Telephone Number including area code

Parent/Guardian/Caregiver Name (optional)

Parent/Guardian/Caregiver Phone Number (optional)

User Group

Facility

Date you are attending the facility

Scheduled time of use

Have you been positively diagnosed with COVID-19 in the last 14 days, OR tested for COVID-19 and are awaiting results?

Yes

Have you been in Close Physical Contact with anyone diagnosed with COVID-19 in the last 14 days or with someone who is suspected of having COVID-19 and/or is awaiting COVID-19 test results?

Yes

Are you currently experiencing any COVID-19 symptoms OR experienced any of the symptoms in the last 10 days and you did not get COVID-19 test or did not receive negative COVID-19 test result?

Yes

Symptoms include fever, chills, new or worsening continuous cough, barking cough, shortness of breath, sore throat, difficulty swallowing, runny nose, sneezing or nasal congestion, lost sense of taste or smell, pink eye, unusual or long lasting headache, stomach pain, nausea, vomiting, diarrhea, muscle aches, extreme tiredness.

Have you travelled outside of Canada in the last 14 days or had Close Physical Contact with an international traveler who returned to Canada?

Yes

Statement

I hereby certify that the above information is accurate to the best of my knowledge.

To the extent that the foregoing information constitutes personal information as defined by the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. Chapter M.56, as amended, the information is subject to provisions of that Act and will be used exclusively by the Recreation Department of the Corporation of the Township of Wellesley and the applicable user groups for contact tracing purposes related to Covid-19. Questions about the collection of personal information should be directed to the Clerk, Township of Wellesley, 4639 Lobsinger Line, St. Clements, ON N0B 2M0.

The user agrees to hold and save harmless The Township of Wellesley for any actions, claims or proceedings for injuries, illness, damages, personal loss or other loss, caused by the negligence of the user during the use of the facility.

A to Z Listings: