U12 - COVID-19 Screening Form
Please complete this form before arriving for training.
Email *
Please enter the name of the Player for whom you are completing this form. *
Do you have any of the following NEW or WORSENING symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. **Fever or chills **Cough or barking cough (croup) **Shortness of breath **Sore throat **Difficulty swallowing **Decrease or loss of smell or taste **Pink eye **Runny or stuffy/congested nose **Headache **Digestive issues like nausea/vomiting, diarrhea, stomach pain **Muscle aches **Extreme tiredness **Falling down often *
If you answered YES to the above question, which symptom(s) do you have?
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *
In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? *
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *
In the last 14 days, have you or anyone you live with travelled outside of Canada? *
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *
A copy of your responses will be emailed to the address you provided.
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