Health Screening and Waiver Form

Updated Aug 14th, 2020
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1.     I understand the risks of coming into contact with other people at LTRA, and accept that I could become infected with Covid-19 through exposure at the facility. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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2.     I agree that I will not come to LTRA if I or anyone in my household has had contact of any kind with someone exposed to, or diagnosed with (confirmed or presumptive), Covid-19 in the previous 14 days. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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3.     I agree that I will not come to LTRA if I have any of the following symptoms which are new, or worsened if associated with allergies, chronic or pre-existing conditions:  fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please Note:  If any of these symptoms, or others not noted above, become new or changed from your usual symptoms, then you should stay home and minimize contact with others until you are feeling better.  Complete the AHS Self-Assessment Tool to determine your need for Covid -19 testing.

4.     I agree that if I have returned to Canada from outside the country (including USA) in the past 14 days I will not come to LTRA. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Health Screening and Waiver Form

Health Screening and Waiver Form

Updated Aug 14th, 2020
     I would like to complete and submit this health questionnaire {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Untitled

1.     I understand the risks of coming into contact with other people at LTRA, and accept that I could become infected with Covid-19 through exposure at the facility. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
2.     I agree that I will not come to LTRA if I or anyone in my household has had contact of any kind with someone exposed to, or diagnosed with (confirmed or presumptive), Covid-19 in the previous 14 days. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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3.     I agree that I will not come to LTRA if I have any of the following symptoms which are new, or worsened if associated with allergies, chronic or pre-existing conditions:  fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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4.     I agree that if I have returned to Canada from outside the country (including USA) in the past 14 days I will not come to LTRA. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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