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."


A new form must be completed prior to each activity.
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Email *
Participants Name: *
Participants Role: *
Participants Session: (coach/executive select all that apply) *
Parent/Guardian/Spectator name(s): *
Phone Number *
Date *
Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.  The symptoms listed here are the most commonly associated with COVID-19.  Anyone who is sick or has any symptoms of illness, including those not listed below, should stay home and seek assessment from their health care provider if needed. *
In the last 14 days, I travelled outside of Canada and was told to quarantine or in the last 14 days, I travelled outside of Canada and was told to not attend school/child care *
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?  This can be because of an outbreak or contact tracing. *
In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate, select “No.” *
In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a PCR test and got a negative result, select “No.” *
Is anyone you live with currently experiencing any new COVID-19 symptoms (listed below) and/or waiting for test results after experiencing symptoms?  Children (17 years old or younger): fever and/or chills, cough or barking cough, shortness of breath, decrease or loss of taste or smell, nausea, vomiting and/or diarrhea.  Adults (18 years old or older): fever and/or chills, cough or barking cough, shortness of breath, decrease or loss of taste or smell, tiredness, muscle aches.  If the person got a COVID-19 vaccine in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” *
In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select "No." *
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 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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