Lloydminster Skating Club - Mandatory Health Screening Questionnaire
This form must be filled out prior to each skate.
Skaters Last Name
Skaters First Name
Does your child have any new onset (or worsening) of any of the following symptoms?
Fever or chills
Shortness of breath / difficulty breathing
Loss of sense of taste or smell
A rash on skin, or discolouration of fingers or toes
Nausea / Vomiting / Diarrhea
muscle aches (unrelated to training)
Congestion or running nose
NONE of the above
Has the attendee travelled outside of Canada in the last 14 days?
Has the attendee had close, unprotected, contact (face to face contact within two meters (six feet) with someone who has travelled outside of Canada in the last 14 days and who is ill (COVID-19 Symptoms)?
Has the attendee had close, unprotected, contact (face to face contact within (six feet) in the last 14 days with someone who is ill (COVID-19 Symptoms)?
Name of Spectator(s) **please put N/A if there will be no spectator**
Spectators declare that they answer NO to the above COVID-19 Health Screening Questions.
No spectator present
Select the following group that you belong to:
Star Skate/ Synchro
Parent & Tot
Skate Canada's mandatory guideline is to have a check in and check out time for every person that enters the arena. Do you confirm that you will be present at start time and depart immediately after practice?
No (please consult your coach)
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service