2021-22 COVID Health Screen (Caledonia Old Timers Hockey)
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2021-22 COVID Health Screen
Player Information
First Name
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Last Name
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Example: ###-###-####
Email Address
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[email protected]
Your submission will be sent to this address.
Hockey & Game Information
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RadDatePicker
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Calendar
Title and navigation
Title and navigation
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Game Time/Ice Pad
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Select One...
9:30pm - Clark Pad
10:00pm - Almas Pad
Position
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Select One...
Full Time Skater
Spare Skater
Goalie
Referee
Timekeeper
Health Question 1: Are you currently experiencing any of these symptoms?
Please answer all questions. The answer to all questions must be “No” in order to participate in any and all activity.
Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher)
*
Yes
No
Do you have the Chills?
*
Yes
No
Do you have a cough that’s new or worsening (continuous, more than usual)
*
Yes
No
Do you have a Barking cough, making a whistling noise when breathing (croup)
*
Yes
No
Do you have Shortness of breath (out of breath, unable to breathe deeply)
*
Yes
No
Do you have a sore throat or difficulty swallowing
*
Yes
No
Do you have a runny nose, sneezing or nasal congestion (not related to seasonal allergies or other known causes or conditions)
*
Yes
No
Do you have a lost sense of taste or smell
*
Yes
No
Do you have pink eye (conjunctivitis)
*
Yes
No
Do you have a headache that’s unusual or long lasting
*
Yes
No
Do you have digestive issues (nausea/vomiting, diarrhea, stomach pain)
*
Yes
No
Do you have muscle aches
*
Yes
No
Do you have extreme tiredness that is unusual (fatigue, lack of energy)
*
Yes
No
Are you falling down often
*
Yes
No
Health Background Questions 2 thru 4
Please answer all questions. The answer to all questions must be “No” in order to participate in any and all activity
2. In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?
*
Yes
No
3. In the last 14 days, have you been in close physical contact with a person who either: Is currently sick with a new cough, fever, or difficulty breathing; OR Returned from outside of Canada in the last 2 weeks?
*
Yes
No
(This does not include essential workers who cross the Canada-US border regularly.)
4. Have you travelled outside of Canada in the last 14 days?
*
Yes
No
(This does not include essential workers who cross the Canada-US border regularly.)
Human Validation
Check The Box
*
Human Validation Failed, Please Try Again
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Thu Jul 07, 2022
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