Health Screening Form – Get Me Out The 4 Walls

Please complete this Health Screening Form before attending a GMOTFW meet or event.

All information provided is taken in confidence and will be deleted 21 days after the meet or event has taken place.

Health Screening Form

Full Name *

Contact Telephone Number *

Date of Meet *

Location of Meet *

1. I can confirm that today I have taken a Lateral Flow Test which has produced a negative result. *

Yes

2. I can confirm that no-one within my household has tested positive for Coronavirus within the last 7 days. *

Yes

3. I can confirm that no-one within my household is currently showing coronavirus symptoms? E.g. New cough, shortness of breath, high temperature or loss of taste or smell? *

Yes

3. I can confirm that I will contact GMOTFW in the event of a positive Lateral Flow Test within 5 days following a GMOTFW meet or event. *

Yes

Should you receive a positive Lateral Flow Test or develop Coronavirus symptoms within 5 days of attending a GMOTFW meet, please inform Lucinda Terry on admin@getmeout.org.uk or call/text 07494898998.