Health questionnaire and covid symptom checker Thank you for booking a Rugby Nippers block. Please now complete the health questionnaire and COVID 19 symptom checker below for your child Health questionnaire and covid symptom checker Your Name* First Last Your Email* Enter Email Confirm Email Child's DetailsAmount of children booking*123Child's 1 Name*Child's 1 Date of Birth* Date Format: MM slash DD slash YYYY Child's 1 Current Age*Child's 2 NameChild's 2 Date of Birth Date Format: MM slash DD slash YYYY Child's 2 Current AgeParent / Guardian DetailsParent / Guardian Name*Address Address Line 1 Address Line 2 City Postcode Emergency ContactsEmergency Contact No. 1*Relationship of Emergency Contact 1 to Child*Child Health QuestionsDoes your child have or has he/ she ever experienced the following? Is there any medical health condition that you need to make our instructors aware off? e.g Asthma, heart, bone or any other conitions? Yes No If you have answered ‘Yes’ to the above question, please write full details here:Is your child currently diagnosed with or believe you have COVID-19 Yes No Additional InfoPhotography DisclaimerBy clicking the checkbox you allow Rugby Nippers to use image(s), or those of your child(ren) if under 18, on Rugby Nippers website and other social media sites, including Facebook, Twitter, Instagram etc? Yes No News LetterWould you like to be added to our quarterly News letter, letting you know when our Easter, Summer and Autumn Rugby Nipper Camps are running? Yes No Parent / Guardian SignatureIn signing this form, I the parent/guardian of the aforementioned child, affirm that I have read this form in its entirety and I have answered the questions accurately and to the best of my knowledge. I understand that my child is responsible for monitoring him or herself throughout any activity, and should any unusual symptoms occur, would cease participation and inform the instructor. I understand that if my child is below the age of six years, I the parent/guardian am responsible for monitoring him or her within their activities. In the event that medical clearance must be obtained prior to my child’s participation in a sports session, I agree to contact the GP and obtain written permission prior to the commencement of the sports activity, and that this permission be given to the instructor. Parent / Guardian Signature:*Name First Last