<form-template> <fields> <field type="header" subtype="h2" label="Town of Englehart COVID-19 Facility Check-In Form" class="header"></field> <field type="paragraph" subtype="blockquote" label="Please complete the following screening questions upon or prior to entering a Municipal facility. Every person must complete the screening every time they enter a facility." class="paragraph"></field> <field type="text" subtype="text" required="true" label="Attendee First and Last Name" class="form-control text-input" name="text-1617279056999"></field> <field type="text" subtype="text" required="true" label="Telephone Number" class="form-control text-input" name="text-1617279270409"></field> <field type="text" subtype="email" required="true" label="Email address" class="form-control text-input" name="text-1617279368514"></field> <field type="date" required="true" label="Date of Visit" class="form-control calendar" name="date-1617279404995" value="Date of Visit"></field> <field type="radio-group" required="true" label="Municipal Facility Check-In" class="radio-group" name="radio-group-1617281427382"> <option value="Municipal Council Chambers" selected="true">Municipal Council Chambers</option> <option value="Englehart Lee Pool">Englehart Lee Pool</option> <option value="Kap Kig Iwan">Kap Kig Iwan Provincial Park</option> <option value="Community Complex - Gym">Community Complex - Gym</option> <option value="Community Complex - Boardroom">Community Complex - Boardroom</option> <option value="Community Complex - Community Hall">Community Complex - Community Hall</option> <option value="Community Complex - Arena">Community Complex - Arena</option> </field> <field type="radio-group" required="true" label="Have you had close contact with a confirmed or probable case of COVID-19 or travelled outside of Canada in the last 14 days?" class="radio-group" name="radio-group-1617285821751"> <option value="Yes" selected="true">Yes</option> <option value="No">No</option> </field> <field type="radio-group" required="true" label="Do you have any of the following new or worsening symptoms or signs: fever or chills, difficulty breathing or shortness of breath, cough, sore throat, trouble swallowing, runny nose/stuffy nose, nasal congestion, decrease or loss of smell or taste, nausea" class="radio-group" name="radio-group-1617285876935"> <option value="Yes" selected="true">Yes</option> <option value="No">No</option> </field> <field type="radio-group" required="true" label="I agree that by ticking this waiver box and that, in using Town of Englehart facilities I do so entirely at my own risk and hereby release Englehart, its staff and suppliers from any and all claims" class="radio-group" name="radio-group-1617286744077"> <option value="I agree" selected="true">I agree</option> <option value="I disagree">I disagree</option> </field> <field type="radio-group" required="true" label="I agree that By ticking this box and clicking the submit button, I agree and consent to the terms of: That this information you provided is accurate and truthful." class="radio-group" name="radio-group-1617285934972"> <option value="I agree" selected="true">I agree</option> <option value="I disagree">I disagree</option> </field> </fields> </form-template> Submit Submitting...