COVID-19 Screening Form (Simcoe Minor Hockey)

Print 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^*

COVID-19 SCREENING QUESTIONNAIRE

Select date and time of activity^*

Open the calendar popup.

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Participant Name^*
Select location of activity^*
Talbot GardensWaterford ArenaPort 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?^*
YesNo
Have you returned from travel outside of Canada in the past 14 days^*
YesNo
Have you been asked to self-isolate^*
YesNo
Have you been in close contact with or had unprotected exposure to a confirmed or probable case of COVID-19?^*
YesNo
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^*
YesNo

Human Validation

Check The Box ^*

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Sat Mar 06, 2021

Printed from simcoeminorhockey.com on Saturday, March 6, 2021 at 6:37 PM

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