U11 A Covid-19 Health Screening Form (Caledon Female Hockey Association)

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U11 A Covid-19 Health Screening Form
This form MUST be filled out for Participants (Players), Members of the Coaching Staff, and any Parents/Guardians entering the rink EACH and EVERY time there is an ice activity.

Participant Information

Please note: This Health Screening questionnaire has been developed based on the Ontario Ministry of Health Self-Assessment Tool (June 17, 2020).

Are you currently experiencing any of these issues? Call 911 if you are.

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 for transplants, corticosteroids, TNF inhibitors)

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

4. Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)

Are you experiencing any of these symptoms?

The answer must be NO in order to participate in each on-ice activity.

For the remaining questions, close physical contact means: Being less than 2 meters away in the same room, workspace, or area for over 15 minutes or living in the same home.

If an individual has answered “Yes” to any of these questions, they are not permitted to participate in any on-ice or off-ice activities.