COVID-19 SCREENING FORM (Port Dover Minor Hockey)

Print COVID-19 SCREENING FORM

CONTACT INFORMATION

Email address^*

A receipt of this submission will be sent to the email address provided. This receipt must be shown at the arena door to gain entry.
Telephone number^*

Example: ###-###-####

COVID-19 SCREENING QUESTIONNAIRE

Select date and time of activity^*

Open the calendar popup.

Open the time view popup.

Exact times can be typed if not available on the time picker.

Enter name of participant^*
Select location of activity^*
Port Dover ArenaWaterford TricenturenaSimcoe Talbot GardensDelhi ArenaLangton Arena
Do you have a fever greater than or equal to 38°C (100.4°F) and/or a new onset of cough or difficulty breathing?^*
YesNo
Have you returned from travel outside of Canada in the past 14 days?^*
YesNo

Arrival date of your return to Canada?

Open the calendar popup.

Not required if you have not travelled outside of Canada in the previous 14 days.

Have you been asked to self-isolate?^*
YesNo
Have you been in close contact with or had unprotected exposure to a confirmed or probable case of COVID-19^*
YesNo
Have you had close contact with or had unprotected exposure to any person with an acute respiratory illness who has returned from travel outside of Canada with the past 14 days prior to their illness onset?^*
YesNo

Human Validation

Check The Box ^*

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Sun Jan 23, 2022

Printed from pdmha.com on Sunday, January 23, 2022 at 1:57 PM