1645 Colborne St. E, Brantford, ON, N3T 5L4
Phone: (519)754-0171   Fax: (519)754-5490
fhunt@csranch.ca - www.csranchgrandriver.ca

CSR Guest COVID Screening


Answer the following questions to help you decide if you should attend your retreat (school trip, weekend retreat etc.) today. The form must be filled out on the day of arrival.

Do you have any of the following symptoms? Please read through the list and check any symptoms that apply to you. If you do not have any symptoms please select None of the above. *
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *
In the last 14 days, have you been identified as a "close contact" of someone who currently had COVID-19? *
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No." *
In the last 14 days, have you travelled outside of Canada? *

If you answered yes to any of the above questions, or you are experiencing symptoms:

1) Do not attend your retreat.
2) Let your Retreat Leader know immediately.