Atom (U11) Tream 5 (Glanbrook Minor Hockey Association)

Atom (U11) Tream 5
Terms and Conditions:

I acknowledge that I will submit this screener no earlier than 12 Hours of each scheduled session, prior to arriving at the arena.  I acknowledge that failure to do so may compromise my registration in the program.

Session Information

Participant Information

Please enter participant's info here.

Parent/Guardian Info

Please enter the name of the parent/guardian who will be dropping and or joining the participant at their session. ***ONLY 1 PARENT PER PARTCIPANT***

Terms and Conditions: Areyoucurrently experiencingany oftheseissues?Cal91ifyou are. You cannot participate in on-ice or off-ice activities. 

1.  Severedifficulty breathing
      can only speak in single words)

2.  Severchestpai(constant tightness o
      crushing sensation)

3.  Feelingconfused orunsureofwhereyouare

4.  Losinconsciousness

Terms and Conditions: If you are in any of the  following at  risk groups,
w as that you speak with your physicia prio to participating:

.  70 years old or older.

2.  Getting  treatment  that  compromises  (weakens
     your  immune  system (for example, 
     chemotherapy, medication
fo transplantscorticosteroids
TN inhibitors)

    3.  Having a condition that compromises (weakens)
you immune system 
(for example, diabetes, emphysema, asthma,
          heart condition)

   4.   Regularly going to a hospital o
          healthcarsetting  for a treatment
         (foexample,dialysissurgery, cancer treatment)

Terms and Conditions: The answer to alquestions must be “No in order to 
participate in any and alactivity (on-ice or off-ice).

1. Are you currently experiencing any of these symptoms?

*Do you have a Fever? (Feeling hot to touch, temperature of 37.8C or higher) 
*Cough that's new or worsening (continuous.more than usual)
*Barking cough, making a whistle noise when breathing (croup) 
*Shortness of breath (out of breath, unable to breathe deepley) 
*Sore throat
*Difficulty swallowing
*Runny nose, sneezing, or nasal congestion (not related to seasonal allergies or  other known causes or conditions) 
*Lost sense of smell or taste
*Pink Eye (conjunctivitis) 
*Headache that's unusual or long lasting
*Digestive Issues (nausea/vomiting, diarrhea, stomach pain) 
*Muscle aches 
*Extreme tiredness that is unusual (fatigue, lack of energy) 
*Falling Down often
*For young children and infants: sluggishness or lack of appetite

Terms and Conditions: The answer  to alquestions must be “No in order 
to participate in any and alactivity (on-ice or off-ice).

r the remaining questionsclose physical contact
means b
eing less than 2  metres away in  the sam roomworkspace, o area 
fo over 15 minutes or living in the same home

*In the last 14 days, hav you  been  in close physical contact with
 someone who  tested positive for COVID-19?

*In the last 14 days, have you beeiclose physical contact
with a persowho either:

*Is currently sicwith a new cough, feverodifficulty breathing;

*Or returned from outside oCanadithe lasweeks?(This does not include essential workers who cross the Canada-US border regularly.)

*Haveyou travelled outsideofCanadithe last14days?(This does not include essential workers who cross the Canada-US border regularly.)

Terms and Conditions: If an individual has answered Yes” t any o these
 questions, they are not permitted  to participate in an
on-ice o off-ice activities.