COVID-19 Attendance/Checklist

2020 COVID-19 Attendance/Checklist
During COVID-19 Pandemic
COVID-19 Document LINK
Name*
First NameLast Name
Family members in same class
Email
example@example.com
Phone Number
Area CodePhone Number
You can only complete this form for one class at a time.
Complete within 24 hours of class.
You must complete this form for each class.
Class Attendance*
SCREENING CHECKLIST
(Source: AHS)

If an individual answers yes to any of the questions, they must not be allowed to participate in the sport. Children and youth will need a parent to assist them to complete this screening tool.

1. Does the person attending the activity have any of the below symptoms:*

	YES	NO
Fever
Cough
Shortness of breath / Difficulty Breathing
Sore Throat
Chills
Painful swallowing
Runny nose / Nasal congestion
Feeling unwell / Fatigue
Nausea / Vomiting / Diarrhea
Unexplained loss of appetite
Loss of taste or smell
Muscle / joint aches
Headache
Conjunctivitis

	YES	NO
2. Have you, or anyone in your household, travelled outside of Canada in the last 14 days?
3. Have you, or your children attending the program has close unprotected contact (face-to-face contact within 2meter / 6 feels) with someone who is ill with cough and/or fever?
4. Have you 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?

If you have answered “yes” to any of the above questions do not participate. Go home and use the AHS Online Assessment Tool to determine if testing is recommended.
Should be Empty:

2020 COVID-19 Attendance/Checklist