Athlete Screening
Self Screening
Name *
Date and Time of Lesson/Practice *
MM
/
DD
/
YYYY
Time
:
Do you have any of the following symptoms? Fever, Cough, shortness of breath, sore throat, runny nose *
Have you or anyone in your household travelled outside of Canada in the last 14 days? *
In the last 14 days, have you or anyone in your household been in contact someone who has is being investigated or confirmed to be a case of Covid-19? *
Have you tested positive for Covid-19 within the last 14 days? *
I confirm the information above is correct. *
Required
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