Driver Pre Race Indemnity/Covid Form

Driver Name:

Licence Number

Race Number:

COVID 19 FORM

✓ Appropriate Box YES NO

Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, or flu like symptoms now or in the past 14 days?

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

Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the last 14 days (i.e., less than 2m for more than 15 minutes accumulative 1 day)?

If you have travelled abroad and returned to Ireland recently. If this does not apply to you, do not answer the question. Have you self-isolated for 14 days since returning?

Your Signature

Parent/Guardian Signature if Driver is under 18 years of age

Thanks for submitting!

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