Between the Lines Sports Campus Screening Form

As per Government of Ontario guidelines and in the interest of keeping all of our clients safe, this form must be completed prior to entry of the facility by each individual client. Thank you!

Please note that failure to answer all questions below honestly may lead to your removal from your program/the facility without refund.

Name *

Phone Number *

Are you currently experiencing any of these symptoms? *

Fever and/or Chills

Cough or barking cough

Shortness of breath

Sore throat

Difficulty swallowing

Runny or stuffy/congested nose

Decrease or loss of taste or smell

Pink eye

Headache

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Muscle aches

Extreme tiredness

Falling down often

None of the above

Required

In the last 14 days, have you travelled outside of Canada? *

Yes

In the last 14 days, have you had close contact with anyone who currently has COVID-19? *

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

Yes

In the last 14 days, have you received a COVID Alert exposure notification on your phone? *

Yes

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