COVID Self Declaration Form

COVID-19

WELSH JUDO SELF DECLARATION FORM

This form must be utilised to allow contact tracing and to ensure that you are free from Covid19 symptoms and pose a limited risk to others

It is important that once you have completed and signed this form that you send to or hand over to the person at your club or venue responsible for processing.

To avoid virus transmission, an electronic version of the form is recommended and where possible sent back to the club via email or other electronic means.

First Name

Last Name

Phone

WJA/BJA Licence Number

• I do not currently have symptoms of COVID-19 (new persistent dry cough, fever, loss of taste or smell)

• I have not had a positive test for COVID-19 or onset of symptoms of COVID-19 in the last 10 days. (Individuals who have completed their period of isolation (10 days) and have no remaining symptoms (other than a dry cough or loss of taste or smell which can last for some time) may return to normal activities)

• No member of my household has had symptoms of COVID-19 or has tested

positive for COVID-19 in the last 14 days

• I have not been contacted by a contact tracer from the Test, Trace and Protect Programme and told to isolate in the last 14 days as a contact of someone with confirmed COVID-19

• I have not returned from a country outside of the UK in the last 14 days, other than those on the exempt list

(https://gov.wales/exemptions-self-isolationcoronavirus-covid-19-html)

I agree with the above statement

Date

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

Thanks for submitting!