U11 BULLDOGS COVID-19 SCREENING
Sign in to Google to save your progress. Learn more
First & Last Name of Team Member *
First & Last name of Individual Accompanying Player to the Arena (write NONE if player is coming alone) *
Anyone else who plans to enter the multiplex as spectators for this event list here. (write NONE if no one is coming). *
Has the player or the individuals accompanying the player to the arena experienced any new onset of symptoms including: Fever, Cough, Shortness of Breath/Difficulty Breathing, Sore Throat, Chills, Painful Swallowing, Runny Nose/Nasal Congestion, Feeling Unwell/Fatigued, Nausea/Vomiting/Diarrhea, Unexpected loss of appetite, Loss of sense of taste/smell, Muscle/Joint Aches, Headache, Conjunctivitis (Pink-Eye) *
Required
Has the player or individuals accompanying the player (or anyone in their households) travelled outside of Canada in the last 14 days? *
Required
Has the player or individuals accompanying the player had close UNPROTECTED contact (face to face contact within 2 metres/6 feet) with anyone who is ill with a cough and/or fever? *
Required
Has anyone in the household of those included on this form had close UNPROTECTED contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19? *
Required
Which Arena are you attending? *
If you answered YES to any of the above questions you must ensure to "VIEW ACCURACY" after you submit the form. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms