COVID Daily Checklist
*Note this will be updated as the Government of Alberta and Alberta Health Services update the
questions and requirements.

Please fill out prior to class commencing. Failure to do so will result in your child being unable to participate in class.

Please fill out yes or no. Temperature will be taken inside the gym by a staff member or volunteer member.

Do you have any of the below symptoms:
Email address *
Name of Athlete *
Date of Session *
MM
/
DD
/
YYYY
Do you currently have any COVID-19 related symptoms? Please read this list carefully: 1- FEVER(temperature of 37.8ºC or higher), 2- CHILLS, 3- NEW OR WORSENING COUGH (continuous, more than usual), 4- SHORTNESS OF BREATH (out of breath, unable to breathe deeply), 5- SORE THROAT, 6- DIFFICULTY SWALLOWING, 7- RUNNY, STUFFY OR CONGESTED NOSE (not related to seasonal allergies or other known causes or conditions), 8- LOSS OF TASTE/SMELL, 9- HEADACHE that is unusual or long-lasting, 10- DIGESTIVE ISSUES (nausea/vomiting, diarrhea, stomach pain) *
Required
Time of Session *
Time
:
Parent or Guardian name *
Has the attendee traveled outside of Canada in the last 14 days? *
Required
Has the attendee had close contact* with a confirmed case of COVID-19 in the last 14 days? *
Required
Has the attendee had close contact with a symptomatic** close contact of a confirmed case of COVID-19 in the last 14 days? *
Required
*
*Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing the recommended personal protective
equipment is not considered to be a close contact.
**’Ill/symptomatic’ means someone with COVID-19 symptoms on the list above

*If the participant has answered “YES” to any of the above questions do not participate. Proceed home and use the AHS
Online Assessment Tool to determine if testing is recommended.
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