WORA Covid-19 Daily Attestation
Please complete the below questionnaire maximum 8hrs prior to your scheduled ice time/session.
In order for proper contact tracing, a new form must be complete each time you enter the facility.
Spectator Name (if accompanying participant into the facility)
Name of Group (e.g. U14Red)
U10 - Black
U10 - Red
U10 - White
U12 - Black
U12 - Grey
U12 - Red
U12 - White
U14 - Black
U14 - Red
U14 - White
U16 - Black
U16 - Red
U16 - White
U19 - Black
U19 - Red
CardelRec (CRC) A
CardelRec (CRC) B
Richmond Memorial CC
W Erskine Johnston (Carp)
Does the participant or spectator listed above currently have any Covid-19 related symptoms in accordance with current Ottawa Public Health guidelines? (example: fever, new or worsening cough, difficulty breathing/shortness of breath, loss of taste/smell, nausea/vomiting, abdominal pain/ diarrhea or muscle pain, headache, feeling very unwell)
Has the participant or spectator listed above knowingly been exposed to or been in contact with anyone who has tested positive for Covid-19, in the past 14 days?
Has the participant or spectator listed above recently returned from travelling outside of Canada, in the past 14 days?
By agreeing, I acknowledge that if at any time after submission of this form and my actual session that if my health situation with respect to Covid -19 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 or Beckwith Township upon entering the facility.
If you answered YES to any of the screening questions above, please self isolate right away, contact your health care provider or visit OttawaPublicHealth.ca/Coronavirus for more information.
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