Covid-19 Screening (Burford Minor Hockey)
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Covid-19 Screening
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Covid-19 Screening
Please Pre Screen before arriving to participate. This also helps the County of Brant and Brant County Health Unit comply with the provincial Response Plan by knowing who has visited the building.
Contact
Please Provide Contact Info.
Reason for Visit
*
Player
Coach
Referee
Time Keeper
Volunteer
Executive
Name of Participant
*
Name Parent Guardian Contact
Home Team
Select One...
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U18 Burford LL
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Contact Phone#
*
Example: ###-###-####
Location
Date of Event
*
Time of Event
*
Location
*
Assesment
Do you have a fever greater than or equal to 38°C (100.4°F) and/or a new onset of cough or difficulty breathing?
Yes
No
Have you returned from travel outside of Canada in the past 14 days?
Yes
No
Have you been asked to self-isolate?
Yes
No
Have you been in close contact with or had unprotected exposure to a confirmed or probable case of COVID-19?
Yes
No
Have you had close contact with or had unprotected exposure to any person with an acute respiratory illness who has returned from travel outside of Canada with the past 14 days prior to their illness onset
Yes
No
Do you have flu like symptoms, runny nose, cough, sore throat, diarrhea?
Yes
No
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