Covid-19 Screening Form, U11 (2011 & 2012) (Centre Hastings Minor Hockey)

Print Covid-19 Screening Form
  1. This screening form must be filled out and submitted prior to attending any Centre Hastings Minor Hockey event. Please read and answer all of the following questions:

    Are you sick with a cold/flu or are you displaying any signs of COVID-19 and/or flu-like symptoms?

    Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat and/or runny nose?

    In the last 14 days, have you travelled outside of Canada and been advised to quarantine per the federal quarantine requirements?

    Have you been identified by Public Health as a close contact of someone with COVID-19?

    Have you been told to isolate by Public Health in the last 14 days?

    In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?

    If you have answered YES to any of the above questions, DO NOT enter the facility.

    By submitting this form you agree that the persons named on the form have answered NO to ALL of the above questions.
  2. Please include your first and last name
  3. Please enter a valid email address
  4. Please enter a your current phone number
  5. Please include first and last name
  6. Please list the first and last name of any other persons attending with you
  7. RadDatePicker
    Open the calendar popup.
    Please select date of attendance
  8. Please select location attending
Human Validation
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Printed from on Saturday, January 29, 2022 at 5:36 AM