Covid Screening - KM Vancouver

IKMF Vancity

COVID Mandatory Screening

Information & Disclaimer

Fill out this form the day before EACH class to save time.
Please come with a sports outfit and a bottle of water.
You can begin any time of the year.

By submitting the form and attending the class, you fully accept the risks inherent to this indoor activity, understanding that social distancing may not be possible for some close-combat exercises, and agrees to indemnify and hold harmless KM Vancity and their instructors from any Covid-related health issues including direct or indirect consequences related to Covid.

Covid Screening Form

Full Name

Email Address

You are submitting this form for the class scheduled on:

Are you experiencing any of the following new or worsening symptoms? *

Fever or Chills
Cough
Sore throat
Difficulty breathing
Diarrhea
Nausea and/or vomiting
Extreme fatigue or tiredness
Body aches
Loss of appetite
Headache
Loss of sense of smell or taste

YesNo

In the last 14 days, have you returned from travel outside Canada, including the United States, and been directed to quarantine? If yes, have you completed your quarantine? *
YesNo

Have you been identified as a close contact of a COVID-19 positive case by Public Health? *
YesNo

Have you been told to self-isolate by Public Health or a Health Care Professional? *
YesNo

I confirm that the information given in this form is true, complete and accurate.