Covid Health Screening Questionnaire (Kawartha Minor Hockey)

Print Covid Health Screening Questionnaire
Covid Health Screening Questionnaire to be completed each time before your child goes on the ice.
Are you currently experiencing?
Please answer Yes Or No. The Answer must be "No" to participate in any and all activity.
  1. Not applicable = N/A
Close Physical Contact means:
Being less than 2 meters away in the same room, workspace, or area for over 15 minutes Living in the same home
  1. Yes or No
  2. Yes or No
  3. Yes or No
  4. Yes or No
  1. This questionnaire must be completed by each individual prior to participation in EACH on ice or off ice activity. 

    Please call 911 if you are experiencing:
    1. Severe difficulty breathing (struggling for each breath, can only speak in single words).
    2. Severe chest pain (constant or tightness or crushing sensation).
    3. Feeling confused or unsure where you are.
    4. Losing consciousness.

    If you are in any of the following wish groups, we ask that you speak with your physician prior to participating.
    1. 70 years old or older.
    2. Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors).
    3. Having a condition that compromises (weakens) your immune system. (For example, diabetes, emphysema, asthma, heart conditions.)
    4. Regularly going to a hospital or health care setting for a treatment. (For example, dialysis, surgery, cancer treatment.)
Your Information
Please provide name for who the document is for (i.e. if player documents provide players name and provide parent/guardian info in the extra box provided)
  1. Example: ###-###-####
Human Validation
Printed from on Saturday, October 24, 2020 at 12:57 PM