Online Screening Form

Smart Cookie Club

Stay. Play. Learn.

I have answered "NO" to all of the above quetions. *

By checking this box, I am confirming that I have answered "no" to all of the above questions. ***If you have answered "yes" to any of the above questions, please stay home, self isolate and follow Toronto Public Health advice.

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 > 38.7, cough, shortness of breath, difficulty breathing, decrease or loss of smell or taste? *

Yes

Date *

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), runny or stuffy nose, headache, nausea, vomiting and/or diarrhea, feeling unwell, muscle aches or tired? *

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 anyone in your household traveled outside of Canada in the past 14 days? *

Yes

4. Has anyone in your household been identified as a close contact of someone who is confirmed as having COVID-19 or been told to stay home and self isolate? *

Yes