‏Seiyu Karate Teens/Adults Class‏‏‎ Covid-19 Self Assessment Tool

Seiyu Karate Covid-19 Self Assessment Tool
All parents are required to complete and submit this checklist at the specific time indicated below.
  - Before their child(ren) enter the dojo building and:
  - Between 6:45 pm and 7:40 pm.
Students will be asked to return or stay home if:
  - Their parents or guardians forgot to submit before 7:40 pm.
  - Their parents or guardians submitted before 6:45 pm.
  - They received the assessment of “Please consult your family doctor or nurse practitioner.”


Is your child experiencing any of the following:

* Mild to moderate shortness of breath
* Inability to lie down because of difficulty breathing
* Chronic health conditions that you are having difficulty managing because of difficulty breathing *

Is your child experiencing cold, flu or COVID-19-like symptoms, even mild ones?

Symptoms include: Fever (over 37.5 degrees Celcius), chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches.

While less common, symptoms can also include: stuffy nose, conjunctivitis (pink eye), dizziness, confusion, abdominal pain, skin rashes or discoloration of fingers or toes. *

Has your child travelled to any countries outside Canada (including the United States) within the last 14 days? *

Did you or your child provide care or have close contact with a person with confirmed COVID-19?

(This means you would have been contacted by your health authority’s public health team) *

Come to the dojo. let's train! *

Please DO NOT come to the Dojo! 
Please consult your family doctor or nurse practitioner.
It is recommended to get a COVID-19 test and self-isolate. 
Testing is recommended for anyone, including children of any age, with cold, flu or COVID-19-like symptoms, even mild ones. For more information on testing, visit http://www.bccdc.ca/health-info/diseases-conditions/covid-19/testing
I certify that the information submitted in this application is true and correct to the best of my knowledge.

Signature of Parent / Guardian *