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? if YES, entrance is prohibited. if NO, proceed to the next question. * Yes No 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, I give permission to store and process my data No, I don't consent to storing and processing my data
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