HSSC / GHSSC Health Screening Questionnaire
This form must be filled out and submitted prior to EACH session in order for a skater, coach or volunteer to participate in the activity.

Failure to fill out and submit this form will result in the person being unable to participate in the activity.
The answer to all questions must be "NO" in order to participate in the activity.

Each skater / coach / volunteer /parent in your household must fill out a form before each activity.

The form must be submitted by 3:00 p.m. on the day of the activity.
Email *
Name of Skater / Coach / Volunteer *
Name of accompanying adult *
Cell Phone Number of accompanying adult *
Activity *
Date *
MM
/
DD
/
YYYY
Do you have any of the following symptoms ? *
Yes
No
Fever
New or Worsening Cough
Sore Throat
Nausea / Vomiting / Diarrhea /Abdominal Pain
New Runny Nose / Sneezing (not related to seasonal allegies)
Difficulty swallowing
Lost sense of taste or smell
Chills
Headache
Unexplained fatigue / malaise
Have you traveled outside of Canada or had close contact with anyone who has traveled outside of Canada in the past 14 days ? *
Have you had close contact in the past 14 days with anyone with a new cough, fever, difficulty breathing or confirmed case of Covid-19 ? *
Have you participated in an activity with another speed skating club, or traveled regionally, provincially or nationally to train or compete in the past 14 days ? *
If you have trained with another club, with which club did you train ? *
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy