Covid Declaration NAME(required) Email(required) Date Form Completed(required) Date of Expected Return(required) Have you any of the following symptoms now or in the past 14 days? (Please tick box relevant to you)(required) Cough Fever High Temperature Sore Throat Breathlessness Flu-Like Symptoms None Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?(required) Yes No Are you a close contact person of a person who is confirmed or suspected case of COVID-19 in the past 14 days (i.e lass than 2 metres for more than 15 minutes accumulative in 1 day)?(required) Yes No Have you been advised by a doctor to self-isolate at this time? (required) Yes No Are you currently classified as someone who is medically vulnerable?(required) Yes No Have you or a member of your household returned from travel abroad in the past 14 days?(required) Yes No *** If you answered “Yes” to any of the above, please stay at home and contact the KMS Health & Safety officer on kmscovid@gmail.com*** Please sign the below with Name and Date. I confirm that I have completed the KMS return to rehearsal training and understand my public health responsibility as a member of KMS. (Name/Date)(required) I confirm that if any of the above information changes, I will notify KMS Health & Safety officer as soon as possible. (Name/Date)(required) In signing below, I confirm that the above information is correct and that I am fit to return to rehearsal. (Name/Date)(required) Send Δ
Kilmacud Musical Society 