Covid Screening Form 2020-21 (Official Home of Stoney Creek Minor Hockey Association)

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Print Covid Screening Form 2020-21
  1. Terms and Conditions
     
    I acknowledge that I will submit this screener no earlier than 12 Hours of each scheduled session, prior to arriving at the arena.  I acknowledge that failure to do so may compromise my registration in the program. 
Session Information
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Player Info
Enter Player Information
  1. Enter Player's Name
  2. RadDatePicker
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    Enter Player's Date of Birth
Non Parent Volunteer Info
  1. Example: ###-###-####
Parent Guardian Information
Please enter the name of the parent/guardian who will be dropping and or joining the player at their session. ***ONLY 1 PARENT PER PARTCIPANT***
  1. Example: ###-###-####
  2. Example: [email protected] Your submission will be sent to this address.
  1. Terms and Conditions 1

    Ar
    e you currently experiencing any othese issues? If so then you cannot participate in on-ice or off-ice activities. 

    1.  Severe difficulty breathing (struggling foeacbreath, can only speak in single words)

    2.  Severchest pai(constant tightness ocrushing sensation)

    3.  Feeling confused or unsurowhere you are

    4.  Losinconsciousness

  2. Terms and Conditions 2

    If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating:

    1
    .  70 years old or older.

    2.  Getting  treatment  that  compromises  (weakens
         your  immune  system (for example, 
         chemotherapy, medication
         
    fo transplantscorticosteroids
         
    TN inhibitors)

        3.  Having a condition that compromises (weakens)
           
    you immune system 
          
    (for example, diabetes, emphysema, asthma,
              heart condition)

       4.   Regularly going to a hospital o
              healthcarsetting  for a treatment
             (foexample,dialysissurgery, cancer treatment)

  3. Terms and Conditions 3

    The answer talquestions musbe “No” in order to participate in any and alactivity (on-ice or off-ice).


    1. Ar
    e you currently experiencing any of these symptoms?

    *Do you have a Fever? (Feeling hot to touch, temperature of 37.8C or higher) 
    *Chills
    *Cough that's new or worsening (continuous.more than usual)
    *Barking cough, making a whistle noise when breathing (croup) 
    *Shortness of breath (out of breath, unable to breathe deepley) 
    *Sore throat
    *Difficulty swallowing
    *Runny nose, sneezing, or nasal congestion (not related to seasonal allergies or  other known causes or conditions) 
    *Lost sense of smell or taste
    *Pink Eye (conjunctivitis) 
    *Headache that's unusual or long lasting
    *Digestive Issues (nausea/vomiting, diarrhea, stomach pain) 
    *Muscle aches 
    *Extreme tiredness that is unusual (fatigue, lack of energy) 
    *Falling Down often
    *For young children and infants: sluggishness or lack of appetite


  4. Terms and Conditions 4

    The answer to alquestions must be “No in order to participate in any and alactivity (on-ice or off-ice).


    Fo
    r the remaining questionsclose physical contact
    means b
    eing less than 2  metres away in  the sam roomworkspace, o area 
    fo over 15 minutes or living in the same home

    1. In the last 14 days, hav you  been  in close physical contact with
     someone who  tested positive for COVID-19?

    2. In the last 14 days, have you beeiclose physical contact
     
    with a persowho either:

    3. Is currently sicwith a new cough, feverodifficulty breathing;

    4. Or returned from outside oCanadithe las weeks?(This does not include essential workers who cross the Canada-US border regularly.)

    5. 
    *Have you travelled outsideofCanadithe last14 days?(This does not include essential workers who cross the Canada-US border regularly.)

  5. Terms and Conditions:

    If an individual has answered Yes” t any o these questions, they are not permitted to participate in an
    on-ice o off-ice activities.
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Printed from scmha.ca on Thursday, October 22, 2020 at 5:06 PM