Peewee Daily Health Assessment SSIMBA
ALL players, volunteers, and coaches need to do this quick health screening assessment PRIOR to entering into ALL SSIMBA events (practices, clinics, and games). This is to ensure that everyone is healthy and to enable proper contact tracing should the necessity arise. If you have any of the following signs and symptoms or if you have been in contact with someone who has tested positive for COVID, please DO NOT come. Remain home and instead inform your coach and call HealthLink BC at 8-1-1.
Email *
Date Attending *
Player name *
Name and preferred contact of parent/guardian *
Cell Number *
I have one of the following signs or symptoms TODAY: Fever (body temperature over 37.5 celsius), cough, sneezing, sore throat, abdominal pain, difficulty breathing, disorientation, fatigue/exhaustion, congestion, chills, diarrhea, and/or vomiting. IF YOU HAVE ANY OF THE FOLLOWING SIGNS AND/OR SYMPTOMS, PLEASE STAY HOME AND CALL HEATHLINK BC 8-1-1. If your symptoms are related to allergies, please see a doctor and obtain proof of a clean bill of health so that we can determine it is safe for you to participate. *
I live in a household with someone who has COVID-19 or is showing symptoms of COVID-19. *
I have been in contact with someone who: 1. has COVID-19; 2. has been asked to self-isolate; or 3. is showing symptoms of COVID-19. *
I, or a member of my household have traveled outside of Island Health within the last 14 days. *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy