Covid Screening Form (Midland Penetang Baseball)

Print Covid Screening Form

This form must be completed for all games, practices and training sessions. Please list names of all participants and spectators in your group.

Do you have any of the following new or worsening symptoms?

fever
YesNo
Shortness of breath or difficulty breathing
YesNo
Sore throat
YesNo
Runny nose, sneezing or nasal congestion (in absence of underlying reasons for symptoms such as seasonal allergies and post nasal drip)
YesNo
Difficulty swallowing
YesNo
Decreased sense of or loss of smell or taste
YesNo
Nausea/vomiting, diarrhea, abdominal pain
YesNo
Unexplained fatigue/malaise/muscle ache
YesNo
Chills
YesNo
Headache
YesNo
New or worsening cough
YesNo

Have you, in the past 14 days:

travelled outside of Canada or had close contact with anyone that has travelled outside of Canada ?
YesNo
been asked to quarantine or had close contact with anyone who has been asked to quarantine ?
YesNo
tested positive for COVID-19 or had close contact with a confirmed or suspected case of COVID-19 ?
YesNo

Participant information

Date of Event

Open the calendar popup.

Location
Team (if applicable)

Time of Event

Open the time view popup.

Participant 1 Name

First Name, Last Name
Participant 1 Role
Participant 2 Name

First Name, Last Name
Participant 2 Role
Participant 3 name

First Name, Second name
Participant 3 Role
Participant 4 Name

First Name, Second name
Participant 4 Role

Contact Information

email address

Example: [email protected]
phone contact number

Example: ###-###-####

Signature

Signature (Must be 18 years or older, if not, Parent or Legal Guardian must sign):
By checking this box and typing my name above, I am electronically signing my form.
Please check and submit

Human Validation

Check The Box ^*