Covid 19 Contact Tracing (Whitchurch Stouffville Minor Hockey Association)
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Covid 19 Contact Tracing
This form needs to be filled out prior to every time your player enters any of the arenas in the Town of Whitchurch-Stouffville. The information will only be used to notify anyone that may have come into contact with a positive case of Covid 19. The information is being held internally with the WSMHA .
Contact Information
Which facility are you entering
*
Clipper Complex 1
Clipper Complex 2
Stouffville Arena Pad A
Stouffville Arena Pad B
Today's date
*
RadDatePicker
RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
Title and navigation
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Time of ice booking
*
RadDatePicker
RadDatePicker
Open the time view popup.
Time picker
Time Picker
12:00 AM
12:30 AM
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First name of person entering facility
*
Last name of person entering facility
*
Phone number you can be reached at
*
Example: ###-###-####
Email address you can be reached at
*
Example:
[email protected]
Your submission will be sent to this address.
Cohort and Group number
*
U9 AA
Covid Questions
If you answer "YES" to any of the questions below, you will be refused entry into the facility.
Do you have or have you experienced a fever in the past 14 days
*
NO
YES
Have you received a positive result of COVID-19 test within the past 14 days
*
NO
YES
Have you been in contact with anyone while they had COVID-19 or symptoms of COVID-19 in the past 14 days
*
NO
YES
In the past 14 days, have you expeienced any of the following symptoms not attributed to another health condition: cough, loss of smell or taste, runney nose, shortness of breath, sore throat
*
NO
YES
Consent
By signing and submitting this Covid-19 health-tracking questionnaire, I consent to the use of my first and last name that I have entered below as an adult and/or guardian to be used as an electronic signature in lieu of an original signature on paper
*
input parent or guardian name
Human Validation
Check The Box
*
Human Validation Failed, Please Try Again
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Printed from wsmha.com on Sunday, March 7, 2021 at 9:50 PM
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