Covid 19 Contact Tracing (Whitchurch Stouffville Minor Hockey Association)

Print 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 1Clipper Complex 2

Today's date^*

Open the calendar popup.

Time of ice booking^*

Open the time view popup.

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 Group 1
Jersey colour and number

black #55

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^*
NOYES
Have you received a positive result of COVID-19 test within the past 14 days^*
NOYES
Have you been in contact with anyone while they had COVID-19 or symptoms of COVID-19 in the past 14 days^*
NOYES
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^*
NOYES

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