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Township of Wellesley Facility COVID-19 Screening

As part of our commitment to providing a safe and healthy community, this 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

Telephone Number including area code

Facility

Date you are attending the facility

Time you are attending the facility

Have you been diagnosed with COVID-19 in the last 14 days?

Yes

Have you been in close contact with anyone diagnosed with COVID-19 in the last 14 days?

Yes

Are you currently experiencing ANY COVID-19 symptoms?

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?

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.

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