KMHA COVID-19 Daily Screening Self-Assessment for all U12 AA, A & B Tryout Sessions
COMPLETION OF THIS FORM IS REQUIRED BY ALL PARTICIPANTS PRIOR TO EACH TRYOUT SESSION AT U12.

REMINDER - THIS FORM IS ONLY VALID IF COMPLETED WITHIN 12 HOURS OF TRYOUT START TIME

A new form must be completed prior to attending each tryout session.

The answers to all multiple choice questions must be "NO" and/or "I AGREE" in order to participate in the specified KMHA tryout session.

Sign in to Google to save your progress. Learn more
Email *
Participant's Name (First and Last): *
Participant's Role at the Tryout Session: *
Accompanying Parent/Guardian/Spectator Name (First and Last):  (if no one, enter "N/A" in the field.) *
Date of the KMHA Tryout Session: *
MM
/
DD
/
YYYY
Start time of KMHA Tryout Session: *
Time
:
Arena Location of the Tryout Session: *
Do you (participant, parent, guardian and/or spectator) have any COVID-19 symptoms, including fever and/or chills, cough, shortness of breath, sore throat, difficulty swallowing, runny nose or congestion, decrease of taste or smell, pinkeye, headache, digestive issues, muscle aches, extreme tiredness, or falling down often (for older people) *
Is anyone that you (participant, parent, guardian and/or spectator) live with currently experiencing COVID-19 symptoms, or is awaiting a test result after experiencing symptoms? *If you are fully vaccinated (2 weeks after completion of last required dose), select "NO". *
In the last 14 days have you (participant, parent, guardian and/or spectator) travelled outside of Canada? (if exempt from federal quarantine requirements, select "NO") *
Has a doctor, health care provider, or public health unit told you (participant, parent, guardian and/or spectator) that you should currently be isolating? *
In the last 10 days have you (participant, parent, guardian and/or spectator) tested positive for COVID-19? *If you have since tested negative on a lab based PCR test, select "NO" *
In the last 14 days, have you (participant, parent, guardian and/or spectator) received a COVID alert exposure notification on your cell phone? *If you are fully vaccinated (2 weeks after completion of last required dose), or you have tested negative, select "NO" *
By agreeing, I acknowledge that if at any time after submission of my form and prior to start of my actual KMHA tryout session that if my health situation with respect to COVID has changed I will refrain from attending the event and/or ice session *
By agreeing, I acknowledge that all information above is accurate and I have agreed to follow the policies and procedures put in place by the KMHA upon attending the identified KMHA tryout session *
If you answered YES to any of the screening questions above. go home & self-isolate right away. Visit OttawaPublicHealth.ca/Coronavirus for more information as you may be eligible for a COVID-19 test.
If feeling unwell, contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms