LBA COVID Questionnaire OUTDOOR U11 Team 2
Please fill this form out a minimum of 2 hours PRIOR to the scheduled practice or game.
Participants Name(first &last)
Level
Team
Date of session
MM
/
DD
/
YYYY
Is the participant experiencing any of the following symptoms: fever, sore throat, shortness of breathe, runny nose, nausea, diarrhea, chills, painful swallowing, loss of taste or smell?
Clear selection
Has the participant travelled outside of Canada in the last 14 days?
Clear selection
Has the participant been in direct close contact with someone who is ill, being investigated, or a confirmed contact?
Clear selection
Parent/Guardian name
Parent/Guardian phone number
Parent/Guardian phone email
Submit
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