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.
Participant Name *
Email address *
Spectator Name (if accompanying participant into the facility)
Name of Group (e.g. U14Red) *
Location *
Required
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) *
Required
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? *
Required
Has the participant or spectator listed above recently returned from travelling outside of Canada, in the past 14 days? *
Required
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. *
Required
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. *
Required
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.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy