COVID-19 Sensplex Daily Patron Screening
Please complete the below questionnaire prior to your visit to the Sensplex facility and on the same day as your visit.

REMINDER – THIS FORM IS ONLY VALID IF COMPLETED ON THE DAY OF YOUR ACTIVITY.

A new form must be completed prior to each entrance to the facility.
Email *
Participant Name (First & Last) *
Supervising Parent/Guardian Name - Please note that only 1 adult may accompany each participant. If adult is a coach/trainer, a second parent/guardian may NOT enter. *
Name of User Group (i.e. Senators Summer Camps) *
Location *
Date of Program/ Ice Session *
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Start Time of Program/ Ice Session *
Time
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Do you (participant and/or supervising parent/guardian) currently have any COVID-19 related symptoms? (fever, chills, cough, difficulty breathing, sore throat, runny nose, loss of taste/smell, diarrhea, nausea, vomiting, abdominal pain or nasal congestion)? *
In the last 14 days, have you (participant and/or supervising parent/guardian) had close physical contact with a person who was a confirmed or probable case of COVID-19? This does not include appropriately protected Health professionals or front line workers who had contact while in the performance of their duties. *
In the last 14 days, have you (participant and/or supervising parent/guardian) traveled outside of Canada or have you close physical contact with a person who has returned from travel outside of Canada? This does not include work-related travel for those who are deemed essential workers by the government of Canada. *
In the last 14 days, have you (participant and/or supervising parent/guardian) attended an event or gathering (including sports tournament) other than those which are permitted under Ontario's current re-opening phase? If yes, you must refrain from participating in any activity at a Sensplex facility until 14 days have passed symptom-free. *
By agreeing, I acknowledge that if at any time after submission of my form and my actual ice session that if my health situation with respect to COVID has changed I will refrain from attending the session.
Clear selection
By agreeing, I acknowledge that all information provided above is accurate and I have agreed to follow the policies and procedures put in place by the Sensplex facilities upon entering the building. *
If you answered YES to any of the screening questions above, go home & self-isolate right away. Visit OttawaPublicHealth.ca/Coronavirus for more information as you may be eligible for a COVID-19 test.
If feeling unwell, contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse.
A copy of your responses will be emailed to the address you provided.
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