Request edit access
Figure 8 Skating Club Health Screen
Sign in to Google to save your progress. Learn more
Name *
Type of participant *
Type of Session *
Has the person attending the activity/facility travelled outside of Canada and is required to quarantine as per Federal travel restrictions? *
Have you/your child had close, unprotected contact (face to face contact within 2 metres/6 feet for 15 minutes or longer) with a case of COVID-19 in the last 10 days? *
Does the participant have any of the below symptoms? *
Yes
No
Fever
Cough
Shortness of Breath / Difficulty breathing
Sore Throat
Chills
Painful swallowing
Runny nose / Nasal congestion
Feeling unwell / Fatigued
Nausea / Vomiting / Diarrhea
Unexplained loss of appetite
Loss of sense of taste or smell
Muscle / joint aches (unrelated to training)
Headache
Conjunctivitis (pink eye)
If you have answered YES to any of the above questions do not participate. Proceed home and use the AHS Online Health Assessment Tool to determine if testing is recommended.  
https://myhealth.alberta.ca/Journey/COVID-19/Pages/COVID-Self-Assessment.aspx
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms