Brant County Spectator form 2 (St. George Minor Hockey)

Print Brant County Spectator form 2

Parent/Guardian/Spectator

Parent/Guardian/Spectator Name:^*
Cell Phone Number:^*

Example: ###-###-####
E mail address:^*

Example: [email protected] Your submission will be sent to this address.
Location of session:^*

Date and time of session:^*

I acknowledge that I will submit this screener no earlier than 12 Hours of each scheduled session, prior to arriving at the arena.

I acknowledge that I can submit this form up to 5 minutes to the participants scheduled ice time.

I acknowledge that if I can't complete this questionairre in these time lines I will bring a completed form or retrieve paperwork at the screening table and complete the forms outside the arena.

I agree to the terms and conditions stated above^*
COVID -19 SCREENING CHECKLIST: Patron/ Participant

The County of Brant is committed to providing a safe and healthy work environment for its employees, visitors and business associates. This checklist can be utilized for any participant entering any municipal facility as part of our response to slowing the spread of COVID-19. We appreciate your support in completing the screening of your participants.

This checklist provides basic information only. It is not intended to take the place of medical advise, diagnosis or treatment

The answer to all questions must be "NO" in order to participate in any and all activity held at a County of Brant facility

You must answer all questions Yes or No

Runny nose, sneezing or nasal congestion ( not related to seasonal allergies or other known causes or conditions)
YesNo
Lost sense of taster or smell ?
YesNo
Are you currently experiencing any of these symptoms? Do you have a fever ? (Feeling hot to touch, a temperature of 37.8 C or higher) ^*
YesNo
Chills ?^*
YesNo
Cough that's new or worsening (continous, more than usual)^*
YesNo
Barking cough, making a whistling noise when breathing (croup)^*
YesNo
Shortness of breath ( out of breath, unable to breathe deeply))^*
YesNo
Sore throat (not related to seasonal allergies or other known causes or conditions))^*
YesNo
Lost sense of taste or smell^*
YesNo
Difficulty swallowing ?^*
YesNo
Pink eye (conjunctivitis)^*
YesNo
Headache that's unusal or long lasting^*
YesNo
Digestive issues (nausea/vomiting,diarrhea, stomach pain) (not related to other known causes or conditions)^*
YesNo
Muscle aches that are unusual or long lasting^*
YesNo
Extreme tiredness that is unusual (fatigue, lack of energy)^*
YesNo
Falling down often^*
YesNo
For young children and infants, sluggishness or lack of appetite^*
YesNo

Physical Contact

If an individual has answered "YES" to any questions, they are not permitted to participate in any activities at a County of Brant facility.

1. In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19 ?^*
YesNo
2. In the last 14 days, have you been in close physical contact with a person who either:Is currently sick with a new cough, fever or difficulty breathing: OR returned from outside Canada in the last 2 weeks with new COVID symptons (like a cough, fever or difficulty breathing?^*
YesNo
Have you travelled outside of Canada in the last 14 days ? This doesnot include essential workers who cross the Canada- US border regularly^*
YesNo

For the remaining questions, close physical contact means

1.Being less than 2 metres away in the same room, workplace or area over 15 minutes

2. Living in the same home
Please note: This Health Screening questionnaire has been developed based on the Ontario Ministry of Health Self Assessment Tool located at
https://covid-19.ontario.ca./self-assessment/

Human Validation