St. Finbarr’s A.C. COVID-19 Health Screening Form Please enable JavaScript in your browser to complete this form.Date of Session *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Session *Please SelectMardyke Track at 18:00Tramore Valley Park at 18:00Name *FirstLastRole *Please SelectClub Member/ Session ParticipantCoachCOVID SupervisorPhone *Email *Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days? *YesNo Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *YesNoAre you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2 metres for more than 15 minutes altogether in 1 day)? *YesNoHave you been advised by a doctor to self-isolate at this time? *YesNoHave you recently visited any of the countries outside Ireland excluding Northern Ireland? *YesNoAre you in a period of self isolation and/or cocooning? *YesNoEmailSubmit
