COVID-19 Health Check - U18/21 Dyer (Lakefield Minor Hockey)

Print COVID-19 Health Check - U18/21 Dyer

Once you have completed this form your coach Steve Dyer will receive a copy. You may only complete this form no sooner than 4 hours and no later than 1 hour before your scheduled ice time.

U18/21 Dyer

Who is this screening form being completed for?

Please Enter Your Name^*

First and Last Name - Player/Bench Staff
Parent/Guardian Attending Arena With Player^*

First and Last Name or enter NO if player attending alone
Contact Number^*
Email Address^*

A copy of your form submission will be sent to this address as confirmation

Screening Questions

If you answer "YES" to any of the questions under this section, do not attend an arena. Contact your child's health care provider for further advice or assessment.

Have you travelled outside of Canada in the past fourteeen (14) days?^*
YesNo
Have you or any member(s) of your household come into close contact with a confirmed or probable case of COVID-19?^*
YesNo
Have you experienced any new or worsening symptoms: fever, cough, runny or stuffy nose, sore throat, trouble swallowing, shortness of breath, difficulty breathing, nausea, vomiting, diarrhea, loss of smell or taste, extreme tiredness or sore muscles?^*
YesNo

Personal information is collected under the authority of the Reopening Ontario (A Flexible Response to COVID-19) Act, 2020, Ontario Regulation 364/20.

The information will be used to screen for COVID-19 risk factors prior to entering a County of Peterborough facility or participating in a hockey program.

In the event of a confirmed COVID-19 diagnosis that coincides with your visit, by completing and submitting this form, you consent to the Lakefield Minor Hockey COVID-19 Coordinator sharing your name and contact information with Peterborough Public Health, for purposes of contact tracing to reduce the spread of COVID-19.

I have answered "NO" to all questions and I will be at hockey today^*