COVID-19 Screening Form 2021-2022 (Clarington Minor Hockey Association)

COVID-19 Screening Form 2021-2022

Terms and Conditions:

I acknowledge that I am submitting this screening form no earlier than 12 Hours prior to the scheduled session. I acknowledge that failure to do so may compromise the participant or the parent/guardian admission into the scheduled program.

The Parent/Guardian & Participant agree to the terms and conditions stated above^*

Session Information

Arena Location^*

Required

Date of Ice Session^*

Required

Time of Ice Session^*

Required

Team^*

Required

Visiting Teams- choose the correct age group and level

Participant, Parent/Guardian Information

Please enter the name of the Participant and parent/guardian who will be arriving with the participant at their session.

Participant Full Name^*

Required

Parent/ Guardian Full Name^*

Required

Enter Referee or Time Keeper if applicable

Phone #^*

Required

Example: ###-###-####

Parent/Guardian Email^*

Required

Example: [email protected]. Your submission will be sent to this address.

Symptoms:

Are you experiencing any of the following:

* Fever or Chills
* Difficulty Breathing or shortness of breath
* Cough
* Sore throat, trouble swallowing
* Runny nose/stuffy nose or nasal congestion
* Loss of Taste or Smell
* Generally Not Feeling Well
* extreme tiredness, sore muscles
* Nausea, Vomiting, Diarrhea

If you answered Yes to any of these symptoms, stay home and do not enter the arena.

The Participant & Parent/Guardian (if attending the session) have answered NO for all the terms and conditions stated above.^*

Travel

Have you Travelled outside of Canada in the past 14 days and been told to quarantine upon your arrival?^*

Required

Close Contact Notification

Within the last 10 days have you been in contact or notified you were in close contact with a confirmed or suspected case of COVID-19?

COVID-19 Screening Form 2021-2022 (Clarington Minor Hockey Association)

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Session Information

Participant, Parent/Guardian Information

Travel

Close Contact Notification

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