Player / Spectator Health Questionnaire RTA
This questionnaire must be completed by each player/spectator prior to attending EACH KWMLA activity.

The team staff will ask you to confirm that you have completed the questionnaire and answered no to all questions before you will be permitted to participate in the activity.  

Are you currently experiencing any of these issues?

Call 911 if you are:
1. Experiencing severe difficulty breathing (struggling for each breath, can only speak in single words)
2. Experiencing severe chest pain (constant tightness or crushing sensation)
3. Feeling confused or unsure of where you are
4. Losing consciousness

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)


The answer to all questions must be “No” in order to participate in each training session.

If an individual has answered “Yes” to any of these questions, they are not permitted to participate in any on-floor activities or attend as a spectator.  Please call your coach or trainer immediately and let them know that you have responded positively to questions in the Health Screening Questionnaire.  

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First name / Player First Name: *
Last name / Player Last Name: *
Contact phone number: *
email address: *
Last name of player: *
Player Division *
What Lacrosse Association are you from? *
What day of the week is the floor time? *
What time is the floor time? *
Time
:
Do you or anyone you live with, have any of the following new or worsening symptoms or signs?*Note: Symptoms should not be chronic or related to other known causes or conditions.Refer to the Ontario COVID-19 worker and employee screening for more information on symptoms.
 Fever and/or chills
  Cough or barking cough (croup)
  Shortness of breath
  Decrease or loss of smell or taste
  Sore throat
  Difficulty swallowing (now distinct from sore throat/difficulty swallowing in
previous version)
  Pink eye
  Runny or stuffy/congested nose
  Headache that’s unusual or long lasting
  Digestive issues like nausea/vomiting, diarrhea, stomach pain
  Muscle aches that are unusual or long lasting
  Extreme tiredness that is unusual
  Falling down often
Are you experiencing any of the above symptoms *
Are you or anyone you live with awaiting COVID-19 test results because of new symptoms of illness? *
In the last 14 days, have you or anyone you live with travelled outside of Canada? *
Have you had close contact with a confirmed or probable case of COVID-19 in the last 14days?           This includes:  a doctor, health care provider, or public health unit has told you that you should currently be isolating (staying at home), and/or  in the past 14 days you have received a COVID Alert exposure notification. If you have since been tested and confirmed negative and have been advised by public health you are not required to self-isolate as a close contact, you may respond“no” *
If you answer YES to any of these questions, please delay your visit and self-isolate right away. Contact your health care provider or Telehealth (1-866-797-0000) for next steps
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