PLAYER INFORMATION *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

PARENT / GUARDIAN INFORMATION *

First Name

Last Name

Fever and/or chills

Yes

Cough or Barking Cough

Yes

Shortness of breath

Yes

Decrease or loss of taste or smell

Yes

Sore throat or difficulty swallowing

Yes

Runny or stuffy nose

Yes

Headache

Yes

Nausea or vomiting

Yes

Extreme tiredness or muscle aches

Yes

NONE OF THE ABOVE!

Yes

Is anyone you live with currently experiencing any new Covid-19 symptoms and/or awaiting test results after experiencing symptoms? *

Yes

No

In the last 14 days, have you travelled outside of Canada *

Yes

No

In the last 14 days, have you been identified as a "close contact" of someone who currently has Covid-19? *

Yes

No

Has a doctor or public health unit told you that you should currently be isolating? *

Yes

No