ISHI YAMA JUDO CLUB
If an additional answers yes to any of the questions, they must not be allowed to participate in the sport. Children and youth will need a parent to assist them to complete this screening tool.
Does the person attending the activity, have any of the below symptoms: *
Yes
No
Fever
Cough
Shortness of Breath / Difficulty Breathing
Sore throat
Chills
Painful swallowing
Runny Nose / Nasal Congestion
Feeling unwell / Fatigued
Nausea / Vomiting / Diarrhea
Unexplained loss of appetite
Loss of sense of test or smell
Muscle / Joint aches
Headache
Conjunctivitis
Have you or anyone in your household traveled outside of Canada in the last 14 days?
Have you or your children attending the program had close unprotected* contact (face-to-face contact within 2 meters/6 feet) with someone who is ill with cough and/or fever?
Have you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?
if you have answered "yes" to any of the above questions DO NOT participate. Go home and use AHS Online Assessment Tool to determine if testing is recommended.

Nether I nor my child have been taking part in other sport group withing the past 14 days.

I ACKNOWLEDGE AND UNDERSTAND THE RISKS RELATED TO TAKING PART IN THE SPORT OF JUDO IN PANDEMIC ENVIRONMENT. I AGREE TO VOLUNTARILY ASSUME ALL RISKS RELATED TO EXPOSURE TO COVID-19 AND AGREE NOT TO HOLD ISHI YAMA JUDO CLUB OR ANY OF ITS OFFICERS, DIRECTORS, COACHES, INSTRUCTORS OR VOLUNTEERS LIABLE FOR ANY ILLNESS OR INJURY. I AGREE THAT THIS IS IN ADDITION TO THE CLUG RELEASE AND INDEMNITY FORM.



Is your GI washed? (It is critical to wash your training equipment before each practice.) *
Phone Number: *
This form was completed for: (Participant Name) *
By *
By completing and submitting this form, you agree to the terms and conditions. A full copy of the T&C can be viewed at http://ishiyamajudoclub.com/ *
Required
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