U15 Tier 2 - Bickmore > U15 Covid-19 Online Assessment (Otonabee Minor Hockey)

Print U15 Covid-19 Online Assessment

Please read through the questionnaire and answer all of the questions. Please answer all questions accurately. Players who arrive at activities and appear to be symptomatic will not be allowed to participate. If your player is not feeling well, or showing any signs of any illness please keep them home. If you have any symptoms or answer yes you must stay home for a minimum of 24 hours after the last symptom subsides. You are given 2 options on the form: *PASS - answered "NO" to all questions and players are permitted to participate *FAIL- answered "YES" to any of the questions and players are NOT permitted to participate. Please notify Coach if your child is not attending and the reasons for missing, this is for tracking purposes.

Player Identification - U15 Only

Player/Bench Staff Full Name^*

First and Last Name
Parent/Guardian Full Name^*

First and Last Name
Contact Number^*
Email Address^*

A copy of your form submission will be sent to this address as confirmation

Call 911 if you are experiencing any of the following symptoms:

- Severe difficulty breathing
- Severe chest pain
- Feeling confused or unsure of where you are
- losing consciousness

Self Assessment

Choose any/all symptoms that are new, worsening and not related to other known causes or conditions.

Have you travelled outside of Canada within the last (14) days?^*
YesNo
Have you or any member(s) of your household come into close contact with a confirmed or probable case of COVID-19?^*
YesNo
Have you experienced any new or worsening symptoms: fever, cough, runny or stuffy nose, sore throat, trouble swallowing, shortness of breath, difficulty breathing, nausea, vomiting, diarrhea, loss of smell or taste, extreme tiredness or sore muscles?^*
YesNo

Personal information is collected under the authority of the Reopening Ontario (A Flexible Response to COVID-19) Act, 2020, Ontario Regulation 364/20.

The information will be used to screen for COVID-19 risk factors prior to entering a County of Peterborough facility or participating in a hockey program.

In the event of a confirmed COVID-19 diagnosis that coincides with your visit, by completing and submitting this form, you consent to the Otonabee Minor Hockey COVID-19 Coordinator sharing your name and contact information with Peterborough Public Health, for purposes of contact tracing to reduce the spread of COVID-19.

I have answered "NO" to all questions and I will be at hockey today^*