Pre-hockey health declaration

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This form must be completed and submitted before the first time you participate in a hockey activity (e.g. training or match).

Should you answer YES to any of questions 1-4, you should NOT attend your club. For question 5, the latest government travel advice applies. Before you resume any hockey activity, you should follow appropriate medical advice and guidelines to ensure you are safe to return to hockey.

Once you have completed the form then, should any of your answers change, contact the Bangor Mens Hockey Covid Officer, George Wilson before you attend a hockey activity.

Name of player *

Date of session *

YYYY

Club section *

Question 1 - Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *

Yes

Question 2 - Have you been told that you are a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days? *

Yes

Question 3 - Have you been advised by a doctor to self-isolate at this time? *

Yes

Question 4 - Are you feeling unwell, have felt unwell or suffered any the following symptoms in the past 14 days? * *

Yes

Cough

Fever/High Temperature

Sore Throat

Loss of smell/taste

New continuous cough

New unexplained shortness of breath

Question 5 - Have you returned from another country within the last 14 days? *

Yes

If yes, where from?

I declare that the above information is true to the best of my knowledge. I agree to inform the Bangor Hockey Club Covid Officer should I develop any symptoms of COVID-19 and, if I do develop those symptoms, I will not participate in club activity until I have medical clearance to do so. (For underage players, this document should be signed by a Parent or Guardian) *

I agree

Required

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