COVID-19 Visitor Form

Visit Details

Name (or name of child/young person that will be visiting)*

Date of visit*

Time of visit*

Which Department will you be visiting?*

Email Address*

Mobile Number*

Have you (or the child/young person whom you are completing this form for) or any member of your household…

1. Have you or any member of your household experienced a high temperature/cough/breathing difficulties/ change to your sense of smell or taste within the last 14 days? *
YesNo
2. Have you or any member of your household been diagnosed with COVID 19 or are currently undergoing testing for COVID 19, within the last 14 days? *
YesNo
3. Have you or any member of your household been requested to restrict movements/ self isolate by health or governmental officials within the last 14 days? *
YesNo
4. Are you fully vaccinated against COVID 19 and received any booster offered to you? (Optional)
YesNo

As you answered no to all questions, you may attend campus at this time.

If your answers to these questions change at any time while you are attending ChildVision services, you are obliged to let a member of staff know immediately.

Please do not visit the ChildVision campus at this time.

Please make contact with the department you were meant to visit to inform them that you cannot attend at this time.

Request submitted for to visit at on .

Contact details provided:
email :
phone:

CREATING A NATIONAL EQUINE ASSISTED THERAPY CENTRE

Visit Details

Have you (or the child/young person whom you are completing this form for) or any member of your household…

As you answered no to all questions, you may attend campus at this time.

Please do not visit the ChildVision campus at this time.

We'd love to hear from you,
So please get in touch.

ChildVision Dublin

ChildVision Cork

Who we are

What we do

How to Help

Research and Training

Resources

Whats Happening