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All individuals staying in the gym for more than 15 minutes must fill out a Camp Self Assessment Questionnaire form prior to entering the gym. All adults must wear a face mask while in the gym for any duration of time.

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Parent First Name

Parent Last Name

Child First Name

Child Last Name

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I affirm that neither my child nor I, nor any other immediate family member, has experienced any signs of illness in the last 72 hours, including but not limited to:

Fever, cough, shortness of breath/ difficulty breathing, sore throat, chills, painful swallowing, runny nose/ nasal congestion,

Feeling unwell/ fatigued, nausea/ vomiting, diarrhea, unexpected loss of appetite, loss of sense of taste and/or smell,

Muscle/ joint aches, headache,

Conjunctivitis (commonly known as pink eye), rash, etc.

I agree that neither my child nor I, nor any other immediate family member, has:

Experienced fever (temperature at or above 38 C or 100.4 F) in the last 72 hours.

Had contact with anyone with a suspected or confirmed COVID-19 case in the last 14 days,

Had contact with anyone with a suspected or confirmed COVID-19 case in the last 14 days with any symptoms listed above,

Traveled outside of Canada in the last 14 days.

Today's Date

I understand that my child is not required to wear a face mask while in the gym, but that wearing a mask is mandatory for all adults staying in the gym for any period of time.

I understand that My gym will keep this information for 14 days and in the case of COVID-19 exposure at the gym , I give consent for My Gym to share this information with Alberta Health Services.

By submmitting this form, you consent to receive emails about My Gym's promotions, upcoming events, and gym news. You can unsubscribe at any time. We respect your right to privacy and will never share your information with any third party.

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Message:

Camp/ PNO Self Assessment Questionnaire