NEW! OGHA Covid-19 Screening Form 2021/2022 (Orangeville Tigers Girls Hockey)

Covid Update (January 3, 2022):

Print 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 REDAlder GREENTonyATonyB

Date:^*

Open the calendar popup.

Which division/team is hosting the ice activity?^*
I am taking this screening as a:^*
Participant (Player)Member of the Coaching StaffParent/GuardianSiblingExecutive/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)?^*
NOYES

Isolation

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying home)?^*
NOYES

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?^*
NOYES

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.