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Health Declaration Form

1. Name(required)

2. Bandname (if applicable)

3. Email(required)

4. Mobile(required)

5. Have you & all of the family members you are living with been following the Government of Canada Social Distancing Recommendation & Procedures?(required)

Yes No

6. Have you or anyone in your household had a suspected case of COVID-19 as assessed by a medical professional?(required)

Yes No

7. Have you tested positive for the COVID-19 virus in the last 14 days?(required)

No Yes and I have self-quarantined and been cleared by a medical professional and now test negative Yes but I have not self quarantined or been cleared by a medical professional

8. In the past 14 days, have you exhibited any of the following symptoms:(required)

Body Chills Fever Coughing Difficulty Breathing Headaches Sore Throat New loss of taste or smell No I have not exhibited any of these symptoms in the last 14 days

9. Have you worked in or visited a building with a recognized COVID-19 case within the last 14 days?(required)

No Yes

10. Have you traveled outside of Canada in the past 21 days?(required)

No Yes (please answer question 10 below)

11. Yes, I have traveled to the following location(s) in the past 21 days:

Declaration: I hereby declare that the details provided above are true and correct to the best of my knowledge and belief and I will undertake to inform the Streetside LIVE! Event Producers of any changes therein, immediately. Please enter your name below.(required)

Date of Declaration(required)

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