2020 Health Screening Form U5, U5 ( Pre School ) - T2 (Ingersoll & District Minor Hockey)

Print 2020 Health Screening Form U5
  1.  
    1. U5 Group

      For players, officials, parents associated with this team ONLY.  Those associated with other groups, find the form set up for that group:  "Health Screening" in website's menu bar, pick desired team from drop-down list.

      This questionnaire must be completed by each individual prior to attendance at each on-ice or off-ice activity.
    1. ONTARIO HOCKEY FEDERATION - Health Screening Questionnaire

      Are you currently experiencing any of these issues? Call 911 if you are.
      1. Severe difficulty breathing (struggling for each breath, can only speak in single words)
      2. Severe chest pain (constant tightness or crushing sensation)
      3. Feeling confused or unsure of where you are
      4. Losing consciousness

      If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating.
      1. 70 years old or older
      2. Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)
      3. Having a condition that compromises (weakens) your immune system (for example, diabetes, emphysema, asthma, heart condition)
      4. Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment) The answer to all questions must be “No” in order to participate in any and all activity.

Participant Info:
Contact, Team and Event information for the Participant or Spectator screened in this form. EACH PERSON NEEDS THEIR OWN FORM. EXAMPLE, ONE PLAYER AND ONE PARENT WATCHING MEANS TWO FORMS ARE NEEDED.
  1. Example: ###-###-####
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    Open the calendar popup.
    1. The answer to all screening questions must be "No" in order to participate in any and all activity.  If one or more questions are answered "Yes", please advise your team's representative immediately and DO NOT ENTER THE ARENA.
Participant Screening
Are you currently experiencing any of these symptoms?
Contacts and Recent Travel
For the remaining questions, close physical contact means: Being less than 2 metres away in the same room, workspace, or area for over 15 minutes - or living in the same home.
Human Validation
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Printed from ingersollminorhockey.ca on Thursday, October 22, 2020 at 11:08 AM