NEW! OGHA Covid-19 Screening Form 2021/2022 (Orangeville Tigers Girls Hockey)
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NEW! OGHA Covid-19 Screening Form 2021/2022
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NEW! OGHA Covid-19 Screening Form 2021/2022
This form must be filled out by all staff, parents/guardians, siblings and participants who are entering the rink each and every time they enter.
Individual Information
Please note: This Health Screening questionnaire has been developed in conjunction with the OWHA and is based on the Ontario Ministry of Health Covid-19 Screening Tool (updated September 2021).
LAST Name
*
FIRST Name
*
Location of Ice Activity
*
Alder RED
Alder GREEN
TonyA
TonyB
Date:
*
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Which division/team is hosting the ice activity?
*
Select One...
FUNdamentals
U7
U8
U9
U11 HL
U11 Competitive
U13 HL
U13 Competitive
U15HL
U15 Competitive
U18/20HL
U18 Competitive
Senior Recreation
I am taking this screening as a:
*
Participant (Player)
Member of the Coaching Staff
Parent/Guardian
Sibling
Executive/Volunteer
Travel Outside of Canada
In the last 14 days, have you travelled outside of Canada and been told to quarantine (per federal quarantine requirements)?
*
NO
YES
Isolation
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying home)?
*
NO
YES
Symptoms
The symptoms listed here are most commonly associated with COVID-19. Choose any/all that are new, worsening, and not related to other known causes or conditions that you already have.
Are you currently experiencing any of these symptoms?
*
Fever and/or chills
Cough or barking cough (croup)
Shortness of breath
Decrease or loss of taste or smell
Muscle aches/joint pain
Extreme tiredness
NONE OF THE ABOVE
Check All That Apply
Positive Test(s)
In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?
*
NO
YES
Verificaiton
You may be asked to confirm your screening. Please be prepared to show your confirmation email.
Please provide an email address to confirm that you have completed the screening:
*
Example:
[email protected]
Your submission will be sent to this address.
Human Validation
Check The Box
*
Human Validation Failed, Please Try Again