U11 C5 Health Check
Sign in to Google to save your progress. Learn more
Please enter your child's first and last name, or your own first and last name. A health check needs to be submitted for every person entering the arena. *
Is this health check for a player, coach/parent/volunteer or game official?
Clear selection
Enter your email: *
Enter your phone number: *
If you are under the age of 18, in the last 14 days have you experienced any of the following symptoms which are new (or worsening if associated with allergies, chronic  or pre-existing conditions). Symptoms include Fever, chills, cough (chronic cough), shortness of breath, loss of smell or taste, diarrhea, nausea and vomiting. *
If you are 18 or older, in the last 14 days have you experienced any of the following symptoms which are new (or worsening if associated with allergies, chronic  or pre-existing conditions). Symptoms include: Fever, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches. While less common, symptoms can also include: stuffy nose, conjunctivitis (pink eye), dizziness, confusion, abdominal pain, skin rashes or discolouration of fingers or toes? *
Are you presently on self-isolation/quarantine due to travel or contact history, as instructed by local health authorities? *
In the past 14 days, did you have close contact with someone who has a probable or confirmed case of COVID 19? If you answer "yes" then you MUST speak with your team COVID Officer before coming to the arena. *
In the past 14 days have you been directed by 811 or public health to be tested or self-isolate? *
If you were asked to be tested have you received your results?
Clear selection
Please be advised that the game may be recorded or streamed live for parent/guardian viewing.
If you answered YES to any of these questions you are not permitted to come to the arena unless 14 days have passed since the onset of symptoms or you received a negative test. By submitting this form, I understand that while Abbotsford Minor Hockey and the City of Abbotsford have taken measures to minimize risk of viral transmission, the nature of my environment means that physical distancing may not always be possible during my time in the arena. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Abbotsford Minor Hockey Association. Report Abuse
Google Forms