Intake Questionnaire

First Name:

Last Name:

Contact phone number:

Emergency Contact Name:

Emergency Contact phone number:

Whitehorse Arrival Date/time/flight number:

Whitehorse Departure Date/Time/flight number:

Do you have any medical conditions we should know about?
YesNo

If yes, please describe:

Do you have any allergies (include foods or food related items)?
YesNo

If yes, please describe?

Please list any foods that you do not eat or that you avoid due to religious, health or you just
plain don’t like them! Please be as specific as possible:

How did you hear about Boréale Ranch and the Yukon?

Health Screening: Please note, this is not a medical assessment. If you are experiencing severe
symptoms, please call 811 or seek medical attention.

Are you a Yukon or BC resident?
YesNo

Have you or anyone from your household travelled outside of Yukon or BC in the last 14 days?
YesNo

Are you experiencing any of the following symptoms?

YesNo
YesNo
YesNo
YesNo
YesNo

Have you had contact with any person with, or under investigation, for COVID-19 in the last 14
days?
YesNo

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