Date * Town facility you are entering * Ballinafad Community Centre Erin Community Centre Hillsburgh Community Centre Station 10 Station 50 Town Hall Roads Shop Full Name * Please enter your first and last name Phone Number * Email * Please enter your email address to receive a confirmation of completion. Are any of the following symptoms new or getting worse? If YES, to two or more symptoms entrance is prohibited. If NO, proceed to the next question. * Fever Sore throat Cough New shortness of breath Muscle aches Fatigue Headache Loss of Smell None of the Above Have you traveled outside of Canada in the last 14 days? * Yes No If you travelled outside of Canada in the last 14 days, did you meet all of the re-entry requirements? Yes No Not Applicable Have you recently had a COVID-19 test and are currently awaiting results? If YES, entrance is prohibited. If NO, proceed. * Yes No Does someone you are in close contact with have COVID-19? If YES, entrance is prohibited. If NO, proceed. * Yes No Consent for storing submitted data * Yes
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