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.

The answer to all questions must be “No” in order to participate in each on-ice activity.
Email address *
Parent/Guardian First & Last Name *
Phone Number *
Skaters First and Last Name *
Skating Group *
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)? *
Do you have shortness of breath? *
Do you have a runny, stuffy or congested nose (not related to other known causes such as seasonal allergies etc.)? *
Do you have a sore throat *
Do you have difficulty swallowing *
Do you have a lost sense of taste or smell? *
Have you travelled outside of Canada in the past 14 days without a Government of Canada Travel Exemption*? *
Have you had close contact in the past 14 days with anyone with a confirmed case of COVID-19, without the consistent and appropriate use of personal protective equipment? *
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 * *
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