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Lloydminster Skating Club - Mandatory Health Screening Questionnaire
This form must be filled out prior to each skate.
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* Indicates required question
Skaters Last Name
*
Your answer
Skaters First Name
*
Your answer
Does your child have any new onset (or worsening) of any of the following symptoms?
*
Fever or chills
Dry Cough
Shortness of breath / difficulty breathing
Sore throat
Feeling fatigued
Loss of sense of taste or smell
Headache
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
Required
Has the attendee travelled outside of Canada in the last 14 days?
*
Yes
No
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)?
*
Yes
No
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)?
*
Yes
No
Name of Spectator(s) **please put N/A if there will be no spectator**
*
Your answer
Spectators declare that they answer NO to the above COVID-19 Health Screening Questions.
*
Agree
Disagree
No spectator present
Select the following group that you belong to:
*
Pre-Can Power
Can Power
Star Skate/ Synchro
Coach
Canskate
Parent & Tot
Adult Synchro
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?
*
Yes
No (please consult your coach)
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