COVID-19 Self Screening Questionnaire 2021-2022

Questionnaire must be completed by each participant and spectator prior to entering the facility.

PLEASE READ CAREFULLY

1. Do you or anyone else indicated on this form have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions. The answer to all questions must be “No” in order to participate in any and all activity. *

Rows	Yes	No
a. Fever and/or chills? (Temperature of 37.8C/100F or higher)
b. Cough or barking cough (croup)?
c. Shortness of breath?
d. Decrease or loss of smell or taste?
e. Fatigue, lethargy, malaise and/or myalgias?
f. Nausea, vomiting and/or diarrhea?

2. In the last 14 days, have you or someone in your household travelled outside of Canada and been advised to quarantine?*

Rows	Yes	No
2. In the last 14 days, have you or someone in your household travelled outside of Canada and been advised to quarantine?

3. Has a doctor, health care provider or public health unit told you that you should currently be isolating? This can be because of an outbreak or contact tracing? *

Rows	Yes	No
3. Has a doctor, health care provider or public health unit told you that you should currently be isolating?

4. In the last 10 days, have you or someone in your household been identified as a 'close contact' of someone who currently has COVID-19? If public health advised that you do not need to self-isolate, select No.*

Rows	Yes	No
4. In the last 10 days, have you or someone in your household been identified as a close contact of someone who currently has COVID-19?

5. In the last 10 days, have you received a COVID alert exposure notification on your cell phone? If you are fully vaccinated and/or have already received a negative test result, select No.*

Rows	Yes	No
5. In the last 10 days, have you received a COVID alert exposure notification on your cell phone?

6. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select No.*

Rows	Yes	No
6. In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?

7. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?*

Rows	Yes	No
7. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

If an individual has answered “Yes” to any of these questions ABOVE , they are not permitted to enter the facility.

8. Following the acknowledgements above, I hereby agree to the following (must answer Yes to agree)**

Rows	Yes	No
COVID19 is a global pandemic and that infections have been confirmed throughout the Province of Ontario, including Windsor-Essex County where the Activity is being administered.
The Organization cannot guarantee my safety or that I won’t be exposed to COVID19 as a result of my participation in the Activity.
I am fully and personally responsible for my own safety and actions while and during my participation in the Activity and I recognize that I may be at risk of contracting COVID19 by my participation in the Activity.
With full knowledge of the risks involved, I hereby release, waive, and discharge the Organization, its employees, owners, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me or anyone claiming through me related to COVID19 as a result of my participation in the Activity while in, on, or around the premises or while using the facilities used in connection with the Activity that may lead to unintentional exposure or ham due to COVID19.
I agree to indemnify, defend, and hold harmless the Organization from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against the Organization due to injury, loss, or death from or related to COVID19 associated with my participation in the Activity.

By signing below I acknowledge that I have read the Waiver and understand its contents. That I am at least eighteen (18) years old and fully competent to give my consent. That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation other than my ability to participate in the Activity.

For Minority Age Children (Under 18 Years of Age)

This is to certify that I, as parent/guardian/adult with responsibility for the below child(ren), have read and explained the provisions in this Waiver to the child(ren) including the risks of the Activity and his/her responsibilities for adhering to the rules and regulations put in place by the Organization in connection with their participation in the Activity.

Parent / Guardian Name*

First NameLast Name

Name of Persons Entering with Parent / Guardian

First NameLast Name

Name of Persons Entering with Parent / Guardian

First NameLast Name

Name of Persons Entering with Parent / Guardian

First NameLast Name

Name of Persons Entering with Parent / Guardian

First NameLast Name

Essex - LibroEssex - Shaheen

Date*

DateHourMinutesAM/PM Option

Phone Number*

Area CodePhone Number

Signature*

Email

example@example.com

Essex Minor Hockey Association