Event Date *

MM

DD

YYYY

Name *

First Name

Last Name

Do you have any of the following symptoms: *

If you answer YES to any of these questions: Please do not attend Lake to Sky View Farm Ltd, stay home and self isolate right away. Call the Health Unit at 1-866-888-4577 ext 5020 for additional direction.

New or worsening cough or shortness of breath

Chills or fever (temperature 37.8 degrees Celsius)

Sore throat or difficulty breathing

Loss of taste or smell

Unusual headache or extreme tiredness

Pink eye

Nausea/vomiting, diarrhea or stomach pain

None of the above

In the past 14 days, have you been in close contact with a confirmed case of Covid-19? *

Yes

No

In the past 14 days, have you travelled outside of Canada? *

Yes

No

In the past 14 days, have you been told by public health that you need to be self-isolating? *

Yes

No

I confirm that the information on this form is accurate to the best of my knowledge *

Yes, I Confirm