Rebellion Hockey COVID-19 Questionaire
If you answer YES to any of the questions below, you MUST NOT come to the practice. Does the person attending the activity, have any of the below symptoms:
Player Name
*
First Name
Last Name
Parent attending Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Do the either parent or Player have a Fever :
*
Yes
No
Shortness of breath/difficulty breathing :
*
Yes
No
Do the either parent or Player have a Cough :
*
Yes
No
Do the either parent or Player have a Sour Throat :
*
Yes
No
Do the either parent or Player have a Chills :
*
Yes
No
Do the either parent or Player have a Painful Swallowing * :
*
Yes
No
Do the either parent or Player have a Runny Nose/Nasal Congestion :
*
Yes
No
Do the either parent or Player feel unwell/Fatigued :
*
Yes
No
Do the either parent or Player have Nausea/vomiting/diarrhea :
*
Yes
No
Do the either parent or Player have Unexplained loss of appetite:
*
Yes
No
Do the either parent or Player have Loss of sense of taste or smell:
*
Yes
No
Do the either parent or Player have Muscle/joint aches:
*
Yes
No
Do the either parent or Player have Conjunctivitis/pink eye:
*
Yes
No
Do the either parent or Player have Headache:
*
Yes
No
Have you, or anyone in your household, travelled outside of Canada in the last 14 days?
*
Yes
No
Have either parent or Player have or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19? :
*
Yes
No
Do you have any medication allergies?
*
Yes
No
Not Sure
Submit
Should be Empty: