Perth Skating Club COVID Health Screening Questionnaire
This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice club/skating school activity. This includes participation in sessions on rented ice outside of a club/skating school setting.

The answer to all questions must be "NO" in order to participate in each on-ice activity.

These questions apply to both the "participant" and the "parent/guardian/spectator."

REMINDER - THIS FORM IS ONLY VALID IF COMPLETED ON THE DAY OF YOUR ACTIVITY.

A new form must be completed prior to each activity.
Email address *
Participants Name: *
Participants Role: *
Required
Participants Session: (coach/executive select all that apply) *
Required
Parent/Guardian/Spectator name: (if accompanying a minor) * *
Phone Number *
Date *
MM
/
DD
/
YYYY
Start Time *
Time
:
Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher) *
Do you have a cough? (That is new or worsening) *
Do you have shortness of breath? *
Do you have a runny, stuffy or congested nose? (not related to other known causes such as seasonal allergies etc.) *
Do you have a sore throat? *
Do you have difficulty swallowing? *
Do you have lost sense of taste or smell? *
Have you travelled outside of Canada in the past 14 days without a Government of Canada Travel Exemption*? *
Have you had close contact in the past 14 days with anyone with a confirmed case of COVID-19, without the consistent and appropriate use of personal protective equipment? *
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 PFSC and the facilities upon entering the building. * *
If the participant and/or the parent/guardian/spectator answered YES to any of the screening questions above, go home and self-isolate right away. Visit www.healthunit.org/coronavirus for more information as you may be eligible for a COVID-19 test. If feeling unwell, contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse. * *
A copy of your responses will be emailed to the address you provided.
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