Daily COVID19 Self Assessment Questionnaire
Covid-19 Declaration - Survey Must be Completed by 4:30 p.m. Daily on Training Days
Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Birth Date
*
Please select a month
January
February
March
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Month
Please select a day
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Day
Please select a year
2024
2023
2022
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Year
Location of Training
*
Vaughan Sportsplex
Ontario Soccer Centre
NRMP # 1
NRMP # 2
McNaughton Turf
St. Joan Turf
Trio Sportsplex
Age Group
*
2013/14 Boys / Girls
2012 Boys
2012 Girls
2011 Boys
2011 Girls
2010 Boys
2010 Girls
2009 Boys
2009 Girls
2008 Boys
2008 Girls
2007 Boys
2007 Girls
2006 Boys
2006 Girls
2005 Boys
2005 Girls
2004 Boys
2004 Girls
2003 Boys
2003 Girls
High Performance Women
High Performance Men
Date of Attendance
*
Time
*
1
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:
Hour
00
10
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30
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50
Minutes
AM
PM
AM/PM Option
1. Are you experiencing any of these COVID-19 like symptoms, that are not a result of an underlying pre-existing health condition: cough, fever, shortness of breath or difficulty breathing, runny and/or stuffy nose, sore throat, trouble swallowing, decrease or loss of smell or taste, nausea, vomiting, diarrhea, abdominal pain, not feeling well, extreme tiredness or sore muscles, chills, headache, dizziness, confusion, muscle or joint aches, skin rashes or discoloration of fingers/toes, conjunctivitis commonly known as pink eye? If you answer “yes”, please advise Sandra Colica , Sergio De Luca and your coach as per Ontario Public Health order, you must self-isolate for a minimum of 14 days from the start of symptoms. You must not come to training
*
YES
NO
2. Have you had close contact with a confirmed or probable case of Covid-19 in the last 14 days?
*
YES
NO
3. Have you travelled outside of Canada in the past 14 days?
*
YES
NO
Signature
Submit
Should be Empty: