Online Screening Form

Smart Cookie Club

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Child's Name: *

1. Does your child have any of the following new or worsening symptoms? (symptoms should not be chronic or related to other known causes or conditions): Fever and/or chills, cough (more than usual if chronic cough), shortness of breath, difficulty breathing, decrease or loss of smell or taste? *

Yes

Date *

Thank you for submitting your form! If you answered YES to any of these questions, keep your child home & self-isolate right away. Call Telehealth or your health care provider, to find out further instructions.

2. Does your child have any of the following new or worsening symptoms? (symptoms should not be chronic or related to other known causes or conditions): sore throat (painful swallowing or difficulty swallowing), headache, nausea, vomiting and/or diarrhea? *

Yes

Smart Cookie Club Online Screening Form

To be filled out by a parent/guardian of a child attending the Smart Cookie Club. The form must be completed on each day that your child is in attendance and any time an individual is entering the SCC facility.

3. Has your child traveled outside of Canada in the past 14 days? *

Yes

5. Has your child been directed by a health care provider including public health official to isolate? *

Yes

4. Has your child been identified as a close contact of someone who is confirmed as having COVID-19 by your local public health unit? *

Yes

(647) 847-8245

info@SmartCookieClub.ca

Website Created and Managed by: Mary Wolff

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