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Funstix COVID-19 Daily Athlete Screening
All athletes participating in any Field Hockey Alberta event, practice or game MUST complete this form PRIOR TO EVERY EVENT.
Individuals will not be allowed access to the field until this form has been completed. Please ensure that it is submitted at least 3 hours prior to your scheduled time.
PLEASE NOTE: If more than one member of your household is participaing, ALL individuals MUST EACH fill out the form or you will NOT be granted access to the event
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* Indicates required question
Email
*
Your email
I understand that I must complete this form or I will not be allowed to participate in the field hockey event.
*
I understand and will complete this form
Required
Date of event:
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MM
/
DD
/
YYYY
Name of event
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Choose
Funstix Auburn Bay
Funstix Mount Pleasant
Funstix Mount Royal
Funstix Panorama Hills/Tuscany/
Coach
First Name of participant
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Your answer
Last Name of participant
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Your answer
If you are filling this form out on behalf of a minor, please enter your full name
Your answer
Best phone number to reach you?
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Your answer
Does the participant have a current FHA membership
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Yes
No
Does the athlete currently participate in any other sports or belong to another cohort group (summer camp, scouts etc)?
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Yes
No
Does the participant currently have COVID-19 (also known as 'Coronavirus')?
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Yes
No
Is the participant waiting for the results of a laboratory test for COVID-19?
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Yes
No
Has the participant been asked to self isolate by Alberta Health, the Communicable Disease Control (CDC) or any other governmental health agency?
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Yes
No
Does the participant have ANY of the following symptoms? Check all that apply.
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Fever (>38C) or have you felt hot or feverish anytime in the last 10 days?
Cough
New or worsening cough
New or worsening shortness of breath?
Difficulty breathing?
Sore throat or painful swallowing?
Runny nose?
Recent loss of smell or taste?
Flu-like symptoms?
Stuffy Nose
Joint Aches
Chills
Pink Eye
NONE
Other:
Required
Has the participant been in contact with any persons or are any members of your household confirmed COVID-19 positive patients?
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Yes
No
Has the participant been in contact with any persons or are any members of your household self-isolating because of a determined risk for possibly having contracted COVID-19?
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Yes
No
Has the participant or any household members frequented a COVID-19 high risk area in Alberta (or elsewhere in Canada) in the last 14 days?
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Yes
No
Has the participant or any household member returned from travel outside of Canada in the past 14 days - whether by car, air, bus, boat or train?
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Yes
No
We are requesting that only the participant enter the event area.
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I understand
I have explained this to the participant and they understand.
Required
Athletes will be required to wear masks when checking in, entering and exiting the field. Please ensure that participants have a properly fitting face mask (face shields are not recommended).
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I understand
I have explained this to the participant and they understand.
Required
Athletes will be required to socially distance from other age group with 3 meters (10 feet) spacing on and off turf.
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I understand
I have explained this to the participant and they understand.
Required
Athletes are not allowed to share equipment with other participants or touch FHA equipment.
*
I understand
I have explained this to the participant and they understand.
Required
Should the athlete experience any symptoms of illness such as a fever, cough, difficulty breathing, shortness of breath or malaise, they will inform representative of Field Hockey Alberta and depart from the event immediately.
*
I understand
I have explained this to the participant and they understand.
Required
By entering your name, participant's name and today's date you hereby agree that you/participant will follow the laws, recommended guidelines and protocols issued by the Government of Alberta and Field Hockey Alberta in respect to COVID-19.
*
Your answer
Do you have any questions or comments?
Your answer
Send me a copy of my responses.
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