JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Ayr Rockets COVID Health Screening
This form must be completed prior to entering any facility associated with the Ayr Rockets Girls Hockey Association by all players, coaches, staff and spectators.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Full Name:
*
Your answer
Phone #:
*
Your answer
Are you currently experiencing any of the following symptoms that are not pre-existing?
*
Fever and/or Chills
Cough or Barking Cough (Croup)
Difficulty Breathing or Shortness of Breath
Decrease or Loss of Smell or Taste
Nausea, Vomitting or Diarrhea
Extreme Tiredness
NONE OF THE ABOVE
Required
In the last 14 days, have you traveled outside of Canada AND been advised to quarantine as per the Federal Quarantine Requirements?
*
Yes
No
Have you been advised by Public Health or a Health Care Practitioner to Self-Isolate in the last 14 days?
*
Yes
No
In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, answer “No”
*
Yes
No
In the last 10 days, have you received a COVID Alert exposure notification on your phone? If you are fully vaccinated or have already gone for a test and got a negative result, please check “No” to this question.
*
Yes
No
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If you are fully vaccinated, please check “No” to this question.
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Ayr Rockets Girls Hockey Association.
Report Abuse
Forms
