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Health Screening Questionnaire
Daily Health Screening
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* Required
Orono Figure Skating Club
This questionnaire must be completed by each individual prior to participation in each activity.
By Submitting this form, you certify the claims made are true. Any misrepresentation places others at risk.
Skater's Name
*
Your answer
Spectator's Name
Your answer
Cell Phone #
*
Your answer
Do you have any of the following symptoms?
Yes
Fever
Aches and Pains
Dry Cough
Sore Throat
Difficulty Breathing
Shortness of Breath
Headache
NONE of the Above
Yes
Fever
Aches and Pains
Dry Cough
Sore Throat
Difficulty Breathing
Shortness of Breath
Headache
NONE of the Above
Are you waiting for a Covid-19 test result, been in close contact with anyone who is a confirmed case of Covid-19 or have been outside of Canada in the past 14 days?
*
Yes
No
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