CHILD SESSION SCREENING (Competitive athlete OR recreational athlete)
Due to the Coronavirus (COVID-19) outbreak we are taking extra precautions with the care of every member to include session tracking, social distancing protocols and enhanced sanitation/disinfection procedures in accordance with the Alberta Health Services. ***This form MUST be filled out ONCE PER SESSION.***

I understand/agree that by answering YES to any questions, on any given day throughout the noted session, the
participant noted above is required to remain home and will not be allowed to attend or participate in any activity or program.

This checklist applies for all children, as well as all students who attend kindergarten through Grade 12, including high school students over 18.

Children may need a parent or guardian to assist them to complete this screening tool.

If your child has traveled outside Canada in the last 14 days, follow the Government of Canada Travel, Testing,
Quarantine and Borders instructions, including any requirements for exempt travelers related to attending high-risk
environments.


*This form will be updated to reflect any Government of Alberta and Alberta Health Services changes to questions and requirements.

SESSION DATES:
Tuesday January 11 to March 15
Thursday January 13 to March 17
Friday January 14 to March 18
Saturday January 7 to March 19
Sign in to Google to save your progress. Learn more
Email *
Session Start Date: *
MM
/
DD
/
YYYY
Session End Date: *
MM
/
DD
/
YYYY
Activity Start Time: *
Time
:
Participant First Name: *
Participant Last Name: *
Class: *
Does the child have any new onset (or worsening) of the following core symptoms: *
Yes
No
Fever (greater than 38℃)
Cough
Shortness of breath/difficulty breathing
Loss of sense of smell or taste
If the child answered “YES” to any symptom in question 1 the child is to isolate for 10 days from onset of symptoms as per CMOH Order 39-2021 or receive a negative COVID-19 test and feel better before returning to activities. Use the AHS Online Assessment Tool or call Health Link 811 to arrange for testing and to receive additional information on isolation. If the child answered “NO” to all of the symptoms in question 1, please proceed to question 2.
Does the child have any new onset (or worsening) of the following other symptoms: *
Yes
No
Chills
Sore throat/painful swallowing
Runny nose/congestion
Feeling unwell/fatigued
Nausea, vomiting and/or diarrhea
Enexplained loss of appetite
Muscle/joint aches
Headache
Conjunctivitis (pink eye)
If the child answered “YES” to ONE symptom in question 2, keep your child home and monitor for 24 hours. If their symptom is improving after 24 hours, they can return to school and activities when they feel well enough to go. Testing is not necessary. If the symptom does not improve or worsens after 24 hours (or if additional symptoms emerge), use the AHS Online Assessment Tool or call Health Link 811 to check if testing is recommended. If the child answered “YES” to TWO OR MORE symptoms in question 2, keep your child home. Use the AHS Online Assessment Tool or call Health Link 811 to determine if testing is recommended. Your child can return to school and activities once their symptoms go away as long as it has been at least 24 hours since their symptoms started. If the child answered “NO” to all questions your child may attend school, child care and/or other activities.
Parent Name: *
Emergency Contact Number: *
If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals’ policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.
By submitting this document electronically, I hereby certify all of the following information to be true. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Leducgymnastics.com. Report Abuse
Google Forms