COVID-19 Screening Form (Simcoe Minor Hockey)
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COVID-19 Screening Form
Contact Information
Email address
*
A receipt of this submission will be sent to the email address provided. This receipt must be shown at the arena door to gain entry.
Telephone Number
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COVID-19 SCREENING QUESTIONNAIRE
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Participant Name
*
Select location of activity
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Talbot Gardens
Waterford Arena
Port Dover Arena
Do you have a fever greater than or equal to 38°C (100.4°F) and/or a new onset of cough or difficulty breathing?
*
Yes
No
Have you returned from travel outside of Canada in the past 14 days
*
Yes
No
Have you been asked to self-isolate
*
Yes
No
Have you been in close contact with or had unprotected exposure to a confirmed or probable case of COVID-19?
*
Yes
No
Have you had close contact with or had unprotected exposure to any person with an acute respiratory illness who has returned from travel outside of Canada with the past 14 days prior to their illness onse
*
Yes
No
Human Validation
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Sat Mar 06, 2021
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COVID-19 Screening Form
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Printed from simcoeminorhockey.com on Saturday, March 6, 2021 at 6:37 PM
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