WMHA Covid-19 Screening Tool & Waiver
Facility:
*
Capri RC Rink A
Capri RC Rink B
Central Park "North"
Central Park "South"
WFCU AM800
WFCU Grenon
WFCU Green Shield
Tecumseh Arena Rink (A)
Tecumseh Arena Rink (B)
Atlas Tube Centre (Rink C)
Atlas Tube Centre (Shuren Rink)
Atlas Tube Centre (The Rock)
Vollmer (A)
Vollmer (B)
Date and Time of Skate/Event
*
Have you or anyone near you travelled outside of Canada in the last 14 days? (Note: This does not include essential workers crossing into the US regularly for work)
*
Yes
No
Have you or anyone near you recently experienced a change in health including: Fever, new or worsening cough, chills, difficulty swallowing, nausea/vomiting, stomach pain, extreme fatigue or difficulty breathing (or a combination of these symptoms)?
*
Yes
No
Muscle aches, fatigue, headache, sore throat, runny nose or diarrhea?
*
Yes
No
Does anyone near you have Covid-19, or have you been in close contact (less than 2 meters) with someone that is Covid-19 positive? (e.g., someone in your household or workplace)?
*
Yes
No
Are you in close contact with a person who is sick with respiratory symptoms (for example, fever, cough or difficulty breathing) who recently travelled outside of Canada?
*
Yes
No
Waiver/Release:
The undersigned agrees that, in using the facilities that WMHA provides he/she does so entirely at their own risk and hereby releases WMHA, its staff and suppliers from any and all claims associated with the use of the facilities, particularly with respect to potential exposure to any virus or pathogen including Covid-19.
OHF Health Screening Questionnaire
By agreeing to the "terms & conditions" below, I successfully completed and passed prior to my arrival, the Ontario Hockey Federation Health Screening Questionnaire.
Which of the following are you entering the facility as?
*
Player
Parent/Guardian
Coach/Volunteer/Official
Board Member
Name
*
First Name
Last Name
Age:
*
Name of Parent/Guardian if Under 18:
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Signature
*
Clear
Submit
Should be Empty: