Health Screening Questionnaire
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.

Sign in to Google to save your progress. Learn more
Email *
Parent/Guardian First & Last Name *
Phone Number *
Skaters First and Last Name *
Skating Group *
1. Choose any/all that are new, worsening, and not related to other known causes or conditions that you already have. *
2. Did the child receive their final (or second in a two-dose series) COVID-19 vaccination dose more than 14 days ago, or have they tested positive for COVID-19 in the last 90 days and have since been cleared? *
3. Is someone that the child lives with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” *
4. In the last 10 days, has the child been identified as a “close contact” of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate, select “No.” *
5. In the last 10 days, has the child received a COVID Alert exposure notification on their cell phone? If they already went for a test and got a negative result, select “No.” *
6. In the last 14 days, has the child travelled outside of Canada AND:• been advised to quarantine as per the federal quarantine requirements AND/OR• is the child under the age of 12 and not fully vaccinated? If travel was solely due to a cross border custody arrangement, select “No.” *
7. Has a doctor, health care provider, or public health unit told you that the child should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing. *
8. In the last 10 days, has the child tested positive on a rapid antigen test or a home-based self-testing kit? If the student/child has since tested negative on a lab-based PCR test, select “No.” *
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 Renfrew Skating Club * *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy