Novice (U9) Team 3 (Glanbrook Minor Hockey Association)

Print Novice (U9) Team 3
  1. 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
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Participant Information
Please enter participant's info here.
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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***
  1. Example: ###-###-####
  2. A copy of your submission will be sent to this email address
  1. 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

  2. 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)

  3. 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

  4. 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.)

  5. 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.
Human Validation