COIVD19 Form & Medical Release

Please fill all parts of the form and return to Edenderry Swimming on arrival

If you feel ill, please stay at Home!!

Name:___________________________________________________________________

Phone Number:___________________________________________________________

Email:___________________________________________________________________

Address:_________________________________________________________________

________________________________________________________________________

Date of birth:_____________________________________________________________

Email Address:____________________________________________________________

Medical Release Form

I CERTIFY THAT, ____________________TO THE BEST OF MY KNOWLEDGE AND BELIEF, (NAME OF THE SWIMMER below) IS IN GOOD PHYSICAL CONDITION AND HAS NO CONDITION WHICH WOULD IMPAIR PARTICIPATION IN THE PROGRAM.  IN CASE OF INJURY, I HEREBY GIVE EDENDERRY SWIMMING POOL LIMITED AND IT’S COACHING, VOLUNTEERS, AND OTHER STAFF PERMISSION TO ACT ON MY BEHALF IN SEEKING MEDICAL TREATMENT FROM ANY LICENSED PHYSICIAN, HOSPITAL OR CLINIC FOR MY CHILD IN THE EVENT THAT SUCH TREATMENT IS DEEMED NECESSARY.  I GIVE PERMISSION TO THOSE ADMINISTERING MEDICAL TREATMENT TO DO SO USING METHODS DEEMED NECESSARY.  I ABSOLVE EDENDERRY SWIMMING POOL LIMITED AND IT’S COACHING STAFF FROM ALL LIABILITY WHILE ACTING ON MY BEHALF IN THIS REGARD

______________________________________________________________________________

COVID19 Information

Have you or swimmer visited any of the countries outside Ireland excluding Northern Ireland?

Yes

No

Are you or swimmer suffering any flu like symptoms?

Yes

No

Are you or swimmer experiencing any difficulty in breathing, shortness of breath?

Yes

No

Did you or swimmer consult a doctor or medical practitioner?

Yes

No

How Are you feeling?

Well

Unwell

Have you or swimmer been in contact with someone who confirmed to have COVID19 has visited an affected region in the past?

Yes

No