COVID-19 Health Screening Questionnaire
This questionnaire must be completed by each individual prior to participation in each Riverside Skating Club activity. The answer to all questions must be "No" in order to participate in each on-ice activity.
1. Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher)
*
YES
NO
2. Do you have any of the following symptoms, Cough, Fever, Runny Noose, Sneezing, or Nasal Congestion (not Related to season allergies), Shortness of Breath, Soar Throat, Difficulty swallowing, Lost Sense of taste or smell?
*
YES
NO
3. Does anyone in your household have any symptoms noted above?
*
YES
NO
4. Have you travelled outside of Canada in the past 14 days or had close contact with anyone that has travelled outside of Canada in the past 14days that does not have a Government of Canada Travel Exemption*?
*
YES
NO
5. Have you had close contact in the past 14 days with anyone with active respiratory illness or an active confirmed or probable case of COVID-19, without the consistent and appropriate use of personal protective
*
YES
NO
6. Have you had close contact in the past 14 days with anyone with active respiratory illness or an active confirmed or probable case of COVID-19,without the consistent and appropriate use of personal protective equipment? or anyone awaiting a result?
*
YES
NO
7. Have you recently been tested for COVID 19 and are awaiting results? Please note - if you were only tested as due to a workplace requirement, please answer no to this question.
*
YES
NO
Date:
/
Month
/
Day
Year
Date
Age:
Skater Name/Parent Name/Coach Name
Parent/Guardian Name to be entered if skater is 18 and under
Choose Program Attending
CanSkatePower/CanPower WEDNESDAY
Advanced CanPower WEDNESDAY
Elite CanPower WEDNESDAY
CanSkate Tuesday
CanSkate Sunday
Senior
Junior
PREJunior
Phone Number
*
-
Phone Number
Signature:
Version 2.0
-
September 10
, 2020
Submit
Should be Empty: