Coronavirus

Name

Personal Email

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you been in close contact with a confirmed case of coronavirus?

Have you been to a COVID19 hoptspot (>10 confirmed cases https://www.nsw.gov.au/covid-19/find-facts-about-covid-19) in the last 14 days.

Are you currently experiencing symptoms (cough, shortness of breath, fever)

Please specify details of the symptoms

How far have you traveled to get to coaching

Did you bring your own handwash/sanitiser

Are you considered a 'high risk' catagory of COVID19 (https://www.healthdirect.gov.au/coronavirus-covid-19-groups-at-higher-risk-faqs)

Do you visit people or have a dependant in the 'high risk' category.

Have you downloaded the COVIDsafe app (https://www.health.gov.au/resources/apps-and-tools/covidsafe-app)

Please note and check each mandatory requirement in place for the duration of coaching with Heath Ryan at 'Fairview Equestrian Center':

By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions outlined above.

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