Covid Screening - IN-HOUSE PROGRAM (Apsley Minor Hockey)

Print Covid Screening - IN-HOUSE PROGRAM

Once you have completed this form your coach or manager will receive a copy. You may only complete this form no sooner than 4 hours and no later than 1 hour before your scheduled ice time.

Player/Parent Information

1. Player/Bench Staff Name

Please enter first and last name
2. Name of Parent/Family Member Attending

Please enter first and last name or leave blank if you are bench staff or if player is attending alone
3. Contact Phone Number
4. Email Adress

A copy of your form submission will be sent to this address as confirmation

5. Date of Game or Practice

Open the calendar popup.

Screening Questions

The answer to all questions must be “No” in order to participate in any and all hockey activities.

1. Have you travelled outside of Canada in the past fourteen (14) days?
YesNo
2. Have you or any member(s) of your household come into close contact with a confirmed or probable case of COVID-19?
YesNo
3. Have you experienced any new or worsening symptoms: fever, cough, runny or stuffy nose, sore throat, trouble swallowing, shortness of breath, difficulty breathing, nausea, vomiting, diarrhea, loss of smell or taste, extreme tiredness or sore muscles?
YesNo