COVID-19 Daily Patron Screening
Please complete the below questionnaire prior to your ice time 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.
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Participant Name (First & Last)
Parent/Guardian Name (if accompanying minor) *
Name of User Group (Crusaders or Warriors) *
Kinburn Sensplex (Cavanaugh)
Date/time of ice session
Do you (participant and/or spectator) 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 spectator) had close physical contact with a person who was a confirmed or probable case of COVID-19? *** If you are fully vaccinated (2 weeks after completion of last required dose), and have not been told by Public Health to isolate, select "NO"
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. *
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 City of Ottawa 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.
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This form was created inside of West Carleton Minor Hockey Association.