Bowmanville FSC Daily Health Screening Questionnaire September 2021
Must be submitted each day of skating
Must be completed prior to arriving at the Arena by 3:00 PM
Must be completed by all Skaters, Coaches and Parents that enter the Facility
The Answer to all questions must be "No" in order to participate in each on-ice activity.
This form is for the following:
NAME of Skater/PA or Coach or Parent/Sibling (every participate requires an individual form submitted)
Date of Session
Contact phone number
The Answer to all questions must be "No" in order to participate in each on-ice activity. Do you have a fever? Cough (continuous, more than usual)? Shortness of Breath? Runny nose, sneezing or nasal congestion (not related to other known causes such as Seasonal Allergies? Sore Throat? Difficulty Swallowing? Lost sense of taste or smell?
Have you travelled outside of Canada in the past 14 days or had close contact with anyone that has travelled outside of Canada in the past 14 days does not have a Government of Canada Travel Exemption*?
Have you had close contact in the past 10 days with anyone with active respiratory illness or an active confirmed or probable case of COVID-19?
Please note: This Health Screening questionnaire has been developed based on the current Ontario Ministry of Health Self-Assessment Tool.
*For information on Travel Exemptions to the emergency order of the Government of Canada's Quarantine Act, please go to :
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Bowmanville Figure Skating Club.