Covid-19 Staff Agreement Form

Personal Information:

Title *

Name *

First

Last

Email *

Contact Number *

Agreements

I confirm that I understand the symptoms that relate to Covid-19 *

Yes
No

I will not attend the club if myself or anyone within my household/support bubble has or develops a fever, cough, or loss of taste/smell or has been advised by NHS Test and Trace to self-isolate. *

Yes
No

I confirm that I have not tested positive for coronavirus. *

Yes
No

I confirm that I have not been advised by NHS Test and Trace to self-isolate. *

Yes
No

I confirm that I have not travelled abroad to any country other than those identified as ‘safe’ by the government within the last 14 days *

Yes
No

I agree to follow the one way drop off and pick up procedure, maintaining social distancing at all times – using the markers provided. *

Yes
No

I understand that no parents or visitors are allowed on site under any circumstances unless prior arrangement has been agreed by management. *

Yes
No

I understand and agree that I must and will have clean clothes, hair, shoes and have a daily shower/bath before work. I will have my hair tied back when at work. *

Yes
No

I understand that although it is not government guidelines, I will wear PPE, face shield, mask, apron and gloves to protect myself, my family and others in the event of an isolation or if physical contact is required with a child or member of staff. *

Yes
No

I understand that my temperature will be taken at the start of my shift and possibly at various points throughout the day. If I develop any symptoms I will be asked to leave and wait in the welfare room whilst my details are collated and will then be asked to go home. *

Yes
No

I will adhere to social distancing guidelines and remain 1+ metres apart from other adults inside and outside of work. *

Yes
No

I understand that full PPE must be worn for toileting and self-care needs for the children in my care and that all surfaces are cleaned after each use. PPE must also be worn when preparing and serving fruit and food to the children. *

Yes
No

I understand that strict enhanced cleaning schedules for all surfaces and equipment will be taking place at various points of the day and it is my responsibility to do this to protect myself, staff and children in my care. Please ensure that you use the alcohol hand rub or sanitiser when at drop off points and before touching any of our areas/surfaces. *

Yes
No

I understand that I should walk/bike or travel in my own car to travel to nursery. Please note the advice of Safer travel guidance. Car sharing is not permitted, https://www.gov.uk/guidance/coronavirus-covid-19-safer-travel-guidance-for-passengers . I understand that if I use public transport, I must wear a face mask which must be removed with safe practice and placed in my personal bag or disposed of in the Covid bins when at the Gap Club. *

Yes
No

I understand that socially distancing young children is not possible, however I agree to keep the children placed in a ‘bubble’ group engaged and focussed on activities that will naturally encourage socially distancing. I agree to come prepared for my shifts at work ready with activities that support the best outcomes for the children in our adapted programmes. *

Yes
No

I understand that social distancing measures are still appropriate outside of The Gap Club and members of my household/support bubble and myself will continue to follow Government advice regarding this. *

Yes
No

I understand that if a child/adult in my bubble shows symptoms of Covid-19 that I will be sent home to self-isolate for 10 days unless a negative test comes back. *

Yes
No

I understand that if I show symptoms of Covid-19 that I must inform The Gap Club and request a test immediately either via calling NHS 119 or by asking my employer to register me for priority testing for essential workers. The result (text or email) must be given to The Gap Club. All children/staff in that bubble will self-isolate for 10 days until test results come back. *

Yes
No

I agree that my name, address, email and phone number can be shared with NHS Test and Trace in the event of a positive test. *

Yes
No

Additional information:

Please add any additonal information you may want to inlclude in the box below:

Agreement Declaration

Required *

I declare that I understand this agreement and that by submitting this electronic agreement to The Gap Club, I am committing to the terms stated herein and confirming that the information given by me in this form is complete and accurate and consent for the information to be held on file by The Gap Club Ltd. I understand that any false information or deliberate omissions or failure to abide by these terms may result in disciplinary actions with unpaid leave and may lead to dismissal from employment.