Sylvan Lake Volleyball Club Daily Screening & Agreement
This form must be completed, signed (typed name is considered your signature) and submitted the day of any SLVC Wave volleyball event. eg: practices, games, all team activities.
* Required
Email address
*
Your email
Is the Participant experiencing any of these symptoms: •Fever • Cough (new cough or worsening chronic cough) •Runny Nose • Sore Throat • Shortness of Breath or difficulty breathing (new or worsening)* •Painful Swallowing •Stuffy Nose •Headache or Chills •Feeling Unwell in general •New Fatigue • Muscle or Joint Aches (not due to the resumption of physical exertion & volleyball activity) •Severe Exhaustion • Gastrointestinal Symptoms (nausea, vomiting, diarrhea or unexplained loss of appetite) • Loss of Smell or Taste • Conjunctivitis (commonly known as pink eye).
*
Yes
No
Has the Participant had close contact with a symptomatic confirmed case of COVID-19 in the last 14 days? Symptomatic means someone with COVID-19 symptoms on the list above.
Yes
No
Clear selection
Has the Participant had close contact with a confirmed case of COVID-19 in the last 14 days? (face-to-face contact within 2 metres)
*
Yes
No
Has the Participant travelled outside of Canada during the past 14 days
*
Yes
No
If you answered YES to any of the above questions, you are NOT permitted to join any SLVC activity today.
BY SIGNING BELOW, the Participant or the Participant’s Guardian agrees that while attending or participating in volleyball, related activities and events in facilities, the Participant: 1. Will follow the laws, recommended guidelines, and protocols issued by the Government of the Alberta in respect of COVID-19, including practicing physical distancing, and will do so to the best of the Participant’s ability while participating in volleyball, related activities and events. 2. Will follow the guidelines and protocols mandated by Volleyball Alberta in respect of COVID-19. 3. Will follow the guidelines and protocols established by the facility being used for volleyball, related activities, and events. 4. Will, in the event that the Participant experiences any symptoms of illness such as a fever, cough, shortness of breath or difficulty breathing, runny nose, or sore throat, immediately: a. Inform a representative of the Organization. b. Go to an identified isolation area apart from other participants and prepare to depart from the event and/or facility.
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19: BY SIGNING BELOW, the Participant (named below) or the Participant or the Participant’s Guardian attests that the Participant has been diagnosed with COVID-19, but been cleared as noncontagious by provincial or local public health authorities and has provided to the Organization, in conjunction with this COVID-19 Daily Screening & Agreement, written confirmation from a medical doctor of the same.
Participant Name (First and Last)
*
Your answer
Participant Date of Birth
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MM
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DD
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YYYY
Participant Team
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Choose
SLVC WAVE 13U
SLVC WAVE 14U
SLVC WAVE 15U
SLVC WAVE 16U
SLVC WAVE 17U
SLVC WAVE 18U
Name of Parent/Legal Guardian (First and Last)
*
Your answer
Parent/Legal Guardian Contact Number
*
Your answer
Document Signed On
*
MM
/
DD
/
YYYY
Send me a copy of my responses.
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