Covid Screening Form (Midland Penetang Baseball)
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Covid Screening Form
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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
Yes
No
Shortness of breath or difficulty breathing
Yes
No
Sore throat
Yes
No
Runny nose, sneezing or nasal congestion (in absence of underlying reasons for symptoms such as seasonal allergies and post nasal drip)
Yes
No
Difficulty swallowing
Yes
No
Decreased sense of or loss of smell or taste
Yes
No
Nausea/vomiting, diarrhea, abdominal pain
Yes
No
Unexplained fatigue/malaise/muscle ache
Yes
No
Chills
Yes
No
Headache
Yes
No
New or worsening cough
Yes
No
Have you, in the past 14 days:
travelled outside of Canada or had close contact with anyone that has travelled outside of Canada ?
Yes
No
been asked to quarantine or had close contact with anyone who has been asked to quarantine ?
Yes
No
tested positive for COVID-19 or had close contact with a confirmed or suspected case of COVID-19 ?
Yes
No
Participant information
Date of Event
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RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
Title and navigation
<<
<
August 2022
>
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August 2022
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M
T
W
T
F
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32
31
1
2
3
4
5
6
33
7
8
9
10
11
12
13
34
14
15
16
17
18
19
20
35
21
22
23
24
25
26
27
36
28
29
30
31
1
2
3
37
4
5
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9
10
Location
Select One...
Tiffin Park
Little Lake Park
Perkinsfield Park
Petersen Park
MacAllan Park
McGuire Park
Away
Team (if applicable)
Select One...
6U BLUE
6U RED
6U GREEN
6U GOLD
6U ORANGE
6U LIGHT BLUE
9U Select
9U BLUE
9U GREEN
9U ORANGE
9U RED
11U Select
11U Blue
13U Select
13U Blue
9U TBA
9U TBA
15U
18U
22U
Senior
Diamond available for booking
Time of Event
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Open the time view popup.
Time picker
Time Picker
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM
Participant 1 Name
First Name, Last Name
Participant 1 Role
Select One...
Player
Coach
Umpire
Official (Scorekeeper, Trainer etc)
Spectator
Participant 2 Name
First Name, Last Name
Participant 2 Role
Select One...
Player
Coach
Umpire
Official (Scorekeeper, Trainer etc)
Spectator
Participant 3 name
First Name, Second name
Participant 3 Role
Select One...
Player
Coach
Umpire
Official (Scorekeeper, Trainer etc)
Spectator
Participant 4 Name
First Name, Second name
Participant 4 Role
Select One...
Player
Coach
Umpire
Official (Scorekeeper, Trainer etc)
Spectator
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
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*
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