U5 COVID Screening Form (Manvers Minor Hockey)

Print U5 COVID Screening Form
This screening tool must be completed by each participant prior to participation in each on-ice or off-ice activity.
Your Information
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  2. Example: ###-###-####
Vaccination Status & COVID-19 Screening
  1. Are you currently experiencing any of these symptoms? 

    • Fever and/or chills

    • Cough or a barking cough (croup)

    • Shortness of breath  

    • Decrease or loss of taste or smell

    • Muscle aches/joint pain

    • Extreme tiredness

    • Sore throat

    • Runny or stuffy/congested nose

    • Headache 

    • Nausea, vomiting and/or diarrhea

  2.  

    1.  In the last 5 days, has someone you live with been sick with symptoms associated with COVID-19 and/or tested positive for COVID-19 (using a Rapid Antigen Test or PCR Test)?

    2.  In the last 5 days, have you tested positive on a Rapid Antigen Test or home based self testing kit?

    3.  Have you been identified as a "close contact" of someone who currently has COVID-19 (confirmed by a PCR or Rapid Antigen Test)?

    4.  
    Have you travelled outside of Canada in the last 14 days? (If exempt from federal quarantine requirements as directed by the border agent at your point of entry, for example, you have 2 or more doses of a COVID-19 vaccine and have met the specific conditions, select "No")

Human Validation
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Printed from manvershockey.com on Monday, May 23, 2022 at 6:34 AM