Athletes Name Athletes First Name Athletes Last Name Parent and/or Legal Guardians Name (if athlete is under 18 years old) Parent and/or Guardian First Name Parent and/or Guardian Last Name Date Health Screening QuestionnaireDo you have a fever? Yes No Are you experiencing cold or flu-like symptoms? Yes No Have you recently traveled anywhere outside of Canada? Yes No Have you knowingly been in contact with someone with a confirmed case of COVID-19 or someone displaying symptoms of the COVID-19 virus? Yes No Do you have any of the following symptoms?Cough Yes No Shortness of Breath Yes No Runny nose, sneezing or nasal congestion (not related to other known causes such as seasonal allergies etc.) Yes No Sore Throat Yes No Difficulty Swallowing Yes No Lost Sense of Taste or Smell Yes No Masks are required at all times when in the Canadian Ice Academy facility.If you answered YES to any of the above questions, you will be denied entry to the Canadian Ice Academy for 14 days. If you make false statements on your Declaration Form, your Membership/Contract to the facility may be suspended or even terminated. This Health Screening questionnaire has been developed based on the current Ontario Ministry of Health Self-Assessment Tool.PhoneThis field is for validation purposes and should be left unchanged.
