Health Screening Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice club/skating school activity. This includes participation in sessions on rented ice outside of a club/skating school setting.

The answer to all questions must be “No” in order to participate in each on-ice activity.

Email *

Name of participant and Parent attending *

1. Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher) Do you have a Cough (that’s new or worsening), shortness of breath, Runny, stuffy or congested nose (not related to other known causes such as seasonal allergies etc.) Sore throat, Difficulty swallowing, Lost sense of taste or smell *

Yes

Required

Have you travelled outside of Canada or had contact with anyone who has travelled outside of Canada in the past 14 days? Have you had close contact in the past 14 days with anyone with a confirmed case of COVID-19? *

Yes

Required

If you have answered Yes to any of the above questions, please do not attend any in person sessions.

https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/latest-travel-health-advice.html#a3

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Mariposa International Training Centre. Report Abuse

Forms