Covid Declaration Form

2.Have you been in close contact (<2m for 15minutes or more) with anyone who is confirmed to have had COVID-19 virus in the last 14 days *YesNo

3.Have you been in close contact (<2m for 15minutes or more) with anyone who is suspected of having COVID-19 virus in the last 14 days? *YesNo

4.Do you live in the same household with someone who has symptoms of COVID-19 who has been in isolation within the last 14 days? *YesNo

5.Have you been advised by a doctor to self-isolate at this time? *YesNo

6.Are you suffering now, or have you suffered any the following symptoms in the past 14 days? Tick the relevant box if you have that symptom. *

CoughBreathing difficultiesFever/High TemperatureSore ThroatRunny NoseFlu-like symptomsRashLoss of smell/tasteNone of the above

7.Have you been advised by a doctor to cocoon? *YesNo

8.Have you returned to Ireland from another country within the last 14 days? *YesNo

9.If yes, where?

10.I confirm that I have not travelled from another country in the past 14 days , that I have not been in close contact with anyone who has been outside of the country in the past 14 days, that I have not been in close contact with anyone who is in self-isolation in relation to COVID-19 in the past 14 days, that I am not suffering from any COVID-19 symptoms nor do I believe for any reason that I have contracted the virus. I commit to advising management and excluding myself if this situation changes, (i.e. if at a point in the future, I would answer “yes” to any of the above questions). Please enter your child's name below. *

11.Parent/Guardian's name: *

12.Child's name: *

13.Signature (confirm your name to act as signature): *

14.Date: *