1 Start 2 Complete Parent name: * Address: * Email Address: * Child Name: * Regional Block Venue: * Do you or your child have symptoms of cough, high temperature (38 degrees Celsius or higher), shortness of breath or sudden loss of sense of taste or smell now or in the past 14 days? * Yes No Have you or your child been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? * Yes No Are you or your child a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2 metres for more than 15 minutes altogether in 1 day)? * Yes No Have you or your child been advised by a doctor to self-isolate at this time? * Yes No Comments relating to COVID-19, not included in the above, which may need to be considered to allow your child/children safely participate in the Centre of Excellence. * Disclaimer Please review these questions daily. If your or your child/children’s situation changes after you complete and submit this form, please ensure you inform FAI representatives immediately.
