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This is screening form is for Adult Participants and Spectators.

*This form will be updated to reflect any Government of Alberta and Alberta Health Services changes to questions and requirements. Due to the Coronavirus (COVID-19) outbreak we are taking extra precautions with the care of every member to include session tracking, social distancing protocols and enhanced sanitation/disinfection procedures in accordance with the Alberta Health Services. This form MUST be filled out EVERY DAY that you are attending AGC. 

I understand/agree that by answering YES to any of the following questions, on any given day throughout the above noted session, the participant noted above is required to remain home and will NOT be allowed to participate in any training sessions, camps, or any other activities. 

First Participant/Spectator Name

First Name*

Last Name*

Phone*
First Participant/Spectator Date of Birth*
I certify that I am 18 years of age or older
First Participant/Spectator Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

First Participant/Spectator Signature*
Second Participant/Spectator Name

First Name*

Last Name*
Second Participant/Spectator Date of Birth*
Second Participant/Spectator Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

Third Participant/Spectator Name

First Name*

Last Name*
Third Participant/Spectator Date of Birth*
Third Participant/Spectator Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

Fourth Participant/Spectator Name

First Name*

Last Name*
Fourth Participant/Spectator Date of Birth*
Fourth Participant/Spectator Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

Fifth Participant/Spectator Name

First Name*

Last Name*
Fifth Participant/Spectator Date of Birth*
Fifth Participant/Spectator Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

Sixth Participant/Spectator Name

First Name*

Last Name*
Sixth Participant/Spectator Date of Birth*
Sixth Participant/Spectator Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

Seventh Participant/Spectator Name

First Name*

Last Name*
Seventh Participant/Spectator Date of Birth*
Seventh Participant/Spectator Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

Eighth Participant/Spectator Name

First Name*

Last Name*
Eighth Participant/Spectator Date of Birth*
Eighth Participant/Spectator Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

Ninth Participant/Spectator Name

First Name*

Last Name*
Ninth Participant/Spectator Date of Birth*
Ninth Participant/Spectator Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

Tenth Participant/Spectator Name

First Name*

Last Name*
Tenth Participant/Spectator Date of Birth*
Tenth Participant/Spectator Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Questions
Has the attendee travelled outside of Canada in the last 14 days?(Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada.)*
No
Yes
Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days? (Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.)*
No
Yes
Do you have any new onset (or worsening) of any of the following symptoms:*
Fever
Cough
Shortness of Breath / Difficulty Breathing
Runny Nose
Sore Throat
Chills
Painful Swallowing
Nasal Congestion
Feeling unwell/fatigued
Nausea/Vomiting/Diarrhea
Unexplained loss of appetite
Loss of sense or smell
Muscle/joint aches
Headache
Pink eye
None of the above

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals' policy. I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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