Name of Participant *

First Name

Last Name

Name of Parent or Guardian *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Permission to collect information electronically *

Yes

No

Have your child or anyone in your household felt hot or feverish in the last 10 days? *

Yes

No

Do you or anyone in your household have any of these symptoms: New or worsening cough? New or worsening shortness of Breath? Difficulty breathing? Sore throat or painful swallowing? Runny nose? *

Yes

No

Has your child had any symptoms of MIS-C including: Fever that lasted 24 hours or longer? Vomiting? Diarrhea? Pain in the stomach? Skin rash? Red eyes? Redness or swelling of the lips and tongue? Feeling unusually tired? Redness and/or swelling of the hands or feet? Headache that’s unusual or long lasting? *

Yes

No

Have you experienced a recent loss of smell or taste? *

Yes

No

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? *

Yes

No

Have you returned from travel outside of Ontario in the last 14 days? *

Yes

No

Is your workplace or the workplace of anyone in your household considered high risk? *

Yes

No

I give permission for my child/teen named as above to attend Hamilton & District Extend-A-Family events recognizing that there is potential risk in in-person events despite the precautions taken. *

Yes

No

Date of Signature *

MM

DD

YYYY