Daily Screening Questionnaire
Dear Parent or Guardian,
Please fill out this questionnaire to determine if your child can attend today.
Athlete's Full Name *
Date *
MM
/
DD
/
YYYY
1. Do you, or your child attending today, have any of the following symptoms?
Fever (greater than 38.0 C) *
Required
Cough *
Required
Shortness of breath or difficulty breathing *
Required
Sore throat *
Required
Chills *
Required
Runny nose or congestion *
Required
Feeling unwell or fatigued *
Required
Nausea, vomiting or diarrhea *
Required
Muscle or joint aches *
Required
Headache *
Required
Unexplained loss of appetite *
Required
Loss of sense of taste or smell *
Required
Conjunctivitis *
Required
2. Have you or anyone in your household, travelled outside of Canada in the past 14 days or to a community with a COVID-19 outbreak? *
Required
3. Have you, or your children attending the program, had close unprotected contact (face-to-face contact within 2 metres) with someone who is ill with cough and/or fever? *
Required
4. Have you or anyone in your household been in close contact (within 2 metres) in the last 14 days with someone that is being investigated for or confirmed to be a case of COVID-19? *
Required
5. Have you, or anyone in your household, been instructed to self-isolate? *
Required
If you have answered "yes" to any of the above questions, DO NOT enter at this time.
If you have recently developed any of these symptoms, please call 811 to see if you require testing.
Please remind your child to use sanitizer before entering and leaving the facility; to refrain from touching their eyes, nose, mouth and face; and to exhibit good respiratory etiquette (sneezing or coughing into the crook of their elbow or a tissue, no spitting, no clearing of nasal passages)
Our goal is to minimize the risk of illness to you, your children and family, and our staff. We thank you in advance for your cooperation and understanding.
I acknowledge, understand, appreciate, and agree that participation may result in possible exposure to and illness from infectious diseases, including, but not limited to COVID-19. While the rules and personal discipline may reduce this risk, the risk of serious illness and death does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others and assume full responsibility for participation and exposure and release the facility, it's employees, officers and directors from any liability related thereto.
Parent or Guardian *
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