COVID Screening (Whitby Girls Hockey Association)

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Participant

Name^*
email^*

[email protected] A confirmation will be emailed to you
Role^*
If other please specify
Arena^*
if other please specify:

Date^*

Open the calendar popup.

Start Time^*

Open the time view popup.

What time is the first game or practice

Until^*

Open the time view popup.

Please enter the end of the last game or practice

1. Are you experiencing any of these symptoms?

The answer to all questions must be "No" in order to participate in each on-ice activity.

Do you have a fever?^*
NoYes
Feeling hot to the touch, a temperature of 37.0C or higher
Chills^*
NoYes
Cough that's new or worsening^*
NoYes
Continuous, more than usual
Barking cough, making a whistling noise when breathing^*
NoYes
Croup
Shortness of Breath^*
NoYes
Out of breath, unable to breathe deeply
Sore Throat^*
NoYes
Difficulty Swallowing^*
NoYes
Runny nose, sneezing or nasal congestion^*
NoYes
not related to seasonal allergies or other known causes or conditions
Lost sense of taste or smell^*
NoYes
Pink Eye^*
NoYes
conjunctivitis
Headache that's unusual or long lasting^*
NoYes
Digestive issues^*
NoYes
Nausea/vomiting, diarrhea, stomach pain
Muscle Aches^*
NoYes
Extreme tiredness that is unusual^*
NoYes
fatigue, lack of energy
Falling down often^*
NoYes
For young children and infants: sluggishness or lack of appetite^*
NoYes

Remaining Questions

For the remaining questions, close physical contact means: Being less than 2 meters away in the same room, workspace, or area for over 15 minutes or living in the same home.

2. In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?^*
NoYes
3 In the last 14 days, have you been in close physical contact with a person who either: Is currently sick with a new cough, fever, or difficulty breathing; OR Returned from outside of Canada in the last 2 weeks?^*
NoYes
4. Have you travelled outside of Canada in the last 14 days?^*
NoYes

Human Validation

Check The Box ^*

COVID Screening (Whitby Girls Hockey Association)

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