I am completing this form for: *

Myself

Someone aged 17 or under who I am responsible for

Name of person completing this form *

First Name

Last Name

Phone *

(###)

###

####

If you are completing this form for someone aged 17 or under, please add THEIR NAME here. Then answer the questions that follow from the perspective of the child.

First Name

Last Name

Date you are due to be attending the Atom creates space *

MM

DD

YYYY

Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in one day)? *

YES

NO

Have you been diagnosed with a confirmed or suspected COVID-19 infection in the last 14 days? *

YES

NO

Have you been advised by a doctor to self-isolate at this time? *

YES

NO

Have you travelled from another country within the last 14 days? *

YES

NO

Are you feeling unwell, have felt unwell, or suffered any of the following symptoms in the past 14 days? Select at least one option. *

A new continuous cough

Fever or high temperature

Unexplained breathing difficulties or shortness of breath

Loss of sense of smell or taste

NONE OF THE ABOVE

I understand that this data is required to be shared with Atom creates for safe operation during the COVID-19 pandemic *

I UNDERSTAND

I am happy for my contact information to also be used by Atom creates for occasional news and promotional updates (This will NEVER be passed on by Atom creates to anyone else) *

YES, I AM HAPPY TO BE CONTACTED

NO THANK YOU