COVID-19 Checklist Order Number COVID Clearance to Participate Checklist 1. Do you have any of the symptoms listed below? First Name * Last name * Fever Chills Cough Barking cough/croup Answer YES or NO below Any of the Symptoms Listed? YesNo Shortness of breath Sore throat Difficulty swallowing Runny Nose 2. Have you been in contact with or cared for someone with COVID-19 in the past 14 days? 3. Have you been in another active cohort? Had Contact in the past 14 Days? YesNo In another active cohort? YesNo 4. Have you been on a trip outside of Canada in the past 14 days? Trip outside of Canada? YesNo 5. Have you had to stay at home in the past two weeks due to being sick? At home sick in past 2 weeks? YesNo If you said NO to all the above, you are free to participate in practice. If you said YES to any of the above, you need to isolate for 14 days before returning to train. Non Essential Self-Travel Report: Please self-report if you have been out of province in the past 7 days and provide details of the travel below: I have travelled outside of the Province of Alberta in the last 7 days. Traveled out of Province? NO YES 1. Location of Travel Location of travel 2. Duration of Trip Duration of trip I declare that all of the above information is correct and reported honestly. Signed Printed name of Parent or Athlete is your signature * Coach * Llew Terry Calli/Richard Deon Date * contact email address *
