The personal information collected through this form is collected under the authority of Municipal Act, 2001, S.O. 2001, c. 25. The information will be used to screen you for heightened COVID-19 risk factors prior to entering the Town of Essex Facilities. In the event of a confirmed COVID-19 diagnosis that coincides with your visit to the facility, your name and contact information may be provided to public health authorities for purposes of contact tracing. Questions about the collection and use of this information should be directed to the Town of Essex at 519-776-7336 ext. 1301.