COVID-19 SELF-ASSESSMENT and INFORMED CONSENT U15 Female
Please complete this questionnaire at least 2 hours before your designated ice time or dry land event.
Please enter your first and last name:
Are you experiencing any of the following?
Severe difficulty breathing (eg. struggling to breath or speaking in single words)
Severe chest pain
Having a very hard time waking up
None of above
Are you experiencing cold, flu or COVID-19 symptoms even mild ones? (Symptoms include: fever, chills, cough, shortness of breath, sore throat, painful swallowing, stuffy or runny nose, loss of smell, headache, muscle aches, fatigue and loss of appetite.)
Have you traveled outside of CANADA in the past 14 days?
Have you provided care or had close contact with a person who: *
Has been diagnosed with COVID-19
Has travelled outside of CANADA in the past 14 days
Is sick with a fever or cough
None of the above
If you checked any boxes other than "none of the above" or "No", do not go to the arena or dry land event, stay home and self isolate. Pay attention to your health and how you are feeling. You can call 8-1-1 anytime to talk to a nurse at HealthLinkBC and get advice about how you are feeling and what to do next. (no response required below)
By signing with my initials, I understand that while Williams Lake Minor Hockey and the Cariboo Memorial Arena have taken measures to minimize risk of viral transmission, the nature of my environment means that physical distancing may not always be possible during my time in the arena. I will make every effort in keeping my surroundings clean with the provided cleaners. Please type the players last name below: *
Send me a copy of my responses.
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