Covid-19 Agreement Form Covid-19 Return to Childcare Questionaire Childs name Childcare Group Preschool Parent / Guardian NameParent / Guardian AddressParent / Guardian Mobile No Please Tick your answers below : Has your child visited any countries (outside Ireland) excluding Northern Ireland in the past 14 days Yes No Is your Child suffering from any of the below Flu or, Covid-19 sysmptoms? Most common symptoms: Fever Yes No Dry Cough Yes No Tiredness Yes No Less common symptoms: Aches and Pains Yes No Sore Throat Yes No Diarrhoea Yes No Conjunctivitis Yes No Loss of taste or smell Yes No Rash or discolouration of fingers or toes Yes No Serious Symptoms: Difficulty breathing or shortness of breath Yes No Chest pain or pressure Yes No Loss of speech or movement Yes No Did you consult a Doctor or other medical practioner in the last 14 days for these or similar symptoms ? Yes No How is your child feeling now? Healthy and Well? Well Unwell Have you or your child been in contact with someone who has tested positive for Covid – 19 in the past 14 days? Yes No Are you, or your child in contact with someone from a Covid-19 at risk category? Yes No Note: When on Site, children will adhere to the on-site standard processes / procedures regarding infection control, i.e. hand washing / hand sanitizing and general coughing / sneezing etiquette. Date MM slash DD slash YYYY SignatureCOVID-19 PARENTAL AGREEMENT FORM Parent / Guardian Name Child’s Name Child’s Play Pod / Class Childs Key Worker Parent / Guardian Emergency Contact Number Please Note that this agreement is in addition to any existing Parent / Guardian agreement. I [ X ] (Parent / Guardians Full Name) agree to the following: That I will complete the “Return to Service Form” for my child The services new arrival and collection procedures which are outside in our Covid-19 Policy and Procedure (Please Request from School) That I will maintain social distancing of 2 meters from other adults and children while at the service and I will not enter the building. Settling – In should be discussed with the Manager That I will NOT bring my child into the service if they are unwell That I will check my child’s temperature each morning before coming into the service and, if it is elevated, I will keep my child at home and contact my GP That my child and I will wash our hands before leaving home and on arrival at the service (use hand gel dispenser if no running water near the entrance) That my child will wear freshly washed clothes each day That my child will NOT bring toys or any other items into the service from home. If a child has a favourite comfort, it can be left in the service for use by the child That I will not leave Buggies or any other equipment at the service The procedures if my child becomes unwell while at the service which are outlined in the Covid-19 Policy (Please Request from School) That I will collect my child immediately if my child becomes unwell while at the service To ensure the emergency contact number is on file and can be contacted That if my child is ill or quarantines normal fees apply Your signature below indicates your agreement with the above statements and confirms you have received a copy of the Covid-19 Policy and Response Plan. Date MM slash DD slash YYYY Signature
