Member Indemnity Form - Covid-19

Full Name

Email Address

Telephone

Gym you're a member of Gym you're a member ofBournemouthSouthamptonGosport

Do you currently display any of the following symptoms? Do you currently display any of the following symptoms?

High temperature (fever)? High temperature (fever)? Yes No

A new or continuous cough? A new or continuous cough? Yes No

Loss or change to your sense of taste or smell? Loss or change to your sense of taste or smell? Yes No

New unexplained shortness of breath? New unexplained shortness of breath? Yes No

To the best of your knowledge, have you been in contact with a Covid-19 confirmed or suspected case in the previous 14 days? To the best of your knowledge, have you been in contact with a Covid-19 confirmed or suspected case in the previous 14 days? Yes No

If you have answered YES to any of these questions you should stay at home and inform the club. You should follow current UK government Public Health Guidelines. Only return to Phoenix MMA once you have sought medical advice and considered not to be at risk of infecting others with Covid-19. If you have answered YES to any of these questions you should stay at home and inform the club. You should follow current UK government Public Health Guidelines. Only return to Phoenix MMA once you have sought medical advice and considered not to be at risk of infecting others with Covid-19.

Typed/Electronic Signature (Parent/Guardian if under 18 years old)

Date __/__/__