PTC Guest Health Assessment Form

Other	Status
West Road Access	Open

/ /

Section 1: Guest Information

Name

Name of Parent/Legal Guardian if Guest is Under 18

Contact Number

Section 2: Symptom Reporting

The questions below should be answered by individuals who are taking part in activities at WinSport facilities. Legal Guardians may assist individuals who are not able to fill in the questionnaire on their own.

If you answer "yes" to any of the questions below you must immediately isolate to your vehicle if one is available. If this is not possible, you must isolate outdoors away from all other persons, activities, and infrastructure.

2.1 Does the attendee currently have any of the following symptoms:

Fever (temp 38.0°C or above)
Cough
Shortness of breath / Difficulty breathing
Sore throat
Chills
Painful swallowing
Runny nose / Nasal congestion
Feeling unwell / Fatigued
Nausea / Vomiting / Diarrhea
Unexplained loss of appetite
Loss of sense of taste or smell
Muscle / Joint aches
Headache
Conjunctivitis (pink eye)

2.1 Answer

Yes

I acknowledge that I have completed this assessment truthfully and to the best of my knowledge. I acknowledge that I have not intentionally taken any medication or taken actions to disguise, alter, lower or diminish any symptoms.