Portobello Orchestra Self Certification Form

The following risk categories for COVID-19 patients have been defined by the National Health Service. Please read through them and assess whether you are fit to attend rehearsals. If you are then please sign and submit the form. You may want to seek further medical advice before you proceed.

1. High risk (clinically extremely vulnerable)

2. Moderate Risk

  1. People at moderate risk from coronavirus:
    • are 70 or older;
    • have a lung condition that is not severe (such as asthma, COPD, emphysema or bronchitis);
    • have heart disease (such as heart failure);
    • have diabetes;
    • have chronic kidney disease;
    • have liver disease (such as hepatitis);
    • have a condition affecting the brain or nerves (such as Parkinson’s disease,┬ámotor neurone disease,┬ámultiple sclerosis or cerebral palsy);
    • have a condition that means they have a high risk of getting infections;
    • are taking medicine that can affect the immune system (such as low doses of steroids);
    • are very obese (a BMI of 40 or above);
    • are pregnant.
  2. People at moderate risk of infecting others:
    • work in a health care or other frontline setting;
    • share a household with people who work in a high-risk environment ie frontline/key workers.

3. Low risk

People at low risk:

Declaration

I have read the above guidance and I assess myself as fit to take part in Portobello orchestra rehearsals, and safe to meet with other members, in a Covid-19 secure environment.




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19th September 2020