Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing any of the following: fever, chills, cough, sore throat, runny nose, stuffy nose, conjunctivitis, dizziness, abdobinal pain, skin rashes, discolouration of fingers or toes, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea, vomiting, muscle aches, chest pain, confusion, loss of consciousness, difficulty waking up.

I am not experiencing any of the following: difficulty breathing, shortness of breath, inability to lie down due to difficulty breathing, chronic health conditions that I am having difficulty managing due to difficulty breathing.

I haven’t been in close contact with a Covid-19 patient in the last 14 days, nor have I been outside Canada in the last 14 days.

Initials

Date

I declare that the info I’ve provided is accurate & complete. I will contact Blue Jellyfish SUP Adventures before attending any program if I exhibit any of the above or other Covid -19 symptoms or if I have been outside of Canada or in contact with a Covid-19 patient in the past 14 days.

Thanks for submitting!

1.778.351.2583

Covid-19 Health Declaration

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@bluejellyfishSUP

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