KMHA COVID-19 Daily Screening Self-Assessment for all U15 Sort Out Sessions
COMPLETION OF THIS FORM IS REQUIRED BY ALL PARTICIPANTS PRIOR TO EACH SORT OUT SESSION AT U15.

REMINDER - THIS FORM IS ONLY VALID IF COMPLETED WITHIN 12 HOURS OF SORT OUT 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 Sort Out session.

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Email *
Participant's Name (First and Last): *
Please enter your Child's Sort Out ID #: *
If the convenor has not provided, please enter '0'.
Participant's Role at the Sort out Session: *
Accompanying Parent/Guardian/Spectator Name (First and Last):  (if no one, enter "N/A" in the field.) *
Date of the KMHA Sort out Session: *
MM
/
DD
/
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Start time of KMHA Sort out Session: *
Time
:
Arena Location of the Sort out 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 Sort out 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 sort out 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.
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