COVID-19 Daily Screening Checklist (under 18)

This is a sample Waiver Form that can be adapted and changed to your organization's needs. You can also configure your waiver form from different samples we offer.

1. Has the child: (Choose any/all possible exposures)

• Traveled outside Canada in the last 14 days? 
   YES  NO
   
• Had close contact with a case of COVID-19 in the last 14 days?
   YES  NO

2. Does the child have any new onset (or worsening) of the following core symptoms:

• Fever
   YES  NO
   
• Cough
   YES  NO
   
• Shortness of breath
   YES  NO
   
• Loss of sense of smell or taste
   YES  NO

If the child answered “NO” to all questions:

• Your child may attend school, child care and/or other activities

You acknowledge that the information provided in this checklist is true and accurate and I understand that no list of restrictions, guidelines or practices will remove 100% of the risk of exposure to COVID-19 as the virus can be transmitted by persons who are asymptomatic and before some people show signs of infection.

I read and accept