COVID 19 Screening Form (Stratford Aces Girls Hockey)

First name^*

Required

Last name^*

Required

Email address^*

Required

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

1. Do you have any of the following new or worsening symptoms or signs? ^*

Fever and/or chills
Cough or barking cough
Shortness of breath
Decrease or loss of taste or smell
Muscle aches
Falling down often
Sore throat or difficulty swallowing
Pink Eye
Runny or stuffy/congested nose
Headache
Nausea, vomitting, diarrhea
Stomach pain
Extreme tiredness

Check All That Apply

2. Have you travelled outside of Canada in the last 14 days? If you are an essential worker who crosses the Canada-US border regularly for work, select “No”.^*

YesNo

Required

3. In the last 14 days, has a public health unit identified you as a close contact of someone who currently has Covid-19?^*

YesNo

Required

4. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?^*

YesNo

Required

5. In the last 14 days, have you received a Covid Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No”.^*

YesNo

Required

If you answer YES to any one of the questions above, PLEASE DO NOT enter this location AND contact your health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment, including if you need a COVID-19 test.

If you have answered yes to any of the questions, please inform your Coach and email the COVID coordinator at [email protected]

I agree to the terms and conditions stated above^*

COVID 19 Screening Form (Stratford Aces Girls Hockey)

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