COVID-19 ATTENDANCE REGISTER
Zumba Swansea
Date*
Day Month Year
Name*
First Name Last Name
Address*
Street Address
Street Address Line 2
City County
Postcode
Date Of Birth
Month Day Year
Date
Phone Number / Mobile*
Email*
example@example.com
SYMPTOMS - Are you experiencing any of the following ?

Do you have a new or persistent cough ?
Do you have a fever ? (above 37.8c)
Have you lost or experiencing a redduwuced sense of taste or smell ?
Have you been in contact with anyone with Covid-19 symptoms or been living in a household with someone who is self-isolating due to Covid-19 Symptoms?
If Yes, Please isolate for 14 days
In the previous 14 days, have you had any COVID-19 symptoms?*
Yes No
In the previous 14 days, have you been in contact with any confirmed/suspected COVID-19 case?*
Yes No
In the previous 14 days, have you travelled internationally?*
Yes No
Have you downloaded and are using the COVIDSafe app?*
Yes No
Signature
Clear
DISCLAIMER
Zumba Swansea reserves the right to refuse entry
Should be Empty:

COVID-19 ATTENDANCE REGISTER

DISCLAIMER