COVID 19 Entry Check (Loyalist Township Minor Hockey)

Print COVID 19 Entry Check

Please complete the screening procedure no earlier than 15 minutes before entry. The form will automatically enter the time that the form is submitted so please follow this expectation. You will be asked by our volunteer at the door to confirm that the form is submitted and complete. The information collected will be stored by Loyalist Township in a secure server for collection by the Public Health Unit if requested. Failure to complete this form may lead to exclusion from further LTMHA events.

Name of player^*
Name of Companion^*

If no spectators enter none.
Phone Number^*

Example: ###-###-#### x###
I have answered NO to all Mandatory questions.^*
YESNO
An answer of NO prohibits entry to facility.
I have answered NO to all Player, Staff Participation Mandatory questions.^*
YESNO
An answer of NO prohibits entry to facility.
No other person other than the player and/or his/her companion who will enter the facility may complete this screening.

This Health Screening Questionnaire has been developed based on the Ontario Ministry of Health Self Assessment Tool (June 17, 2020) and Hockey Canada and the Ontario Hockey Federation

All completed Screening Questionnaires are held in complete confidence and are maintained for Contact Tracing Purposes should the KFLA Health Unit request it.

I have shared this information with our screening volunteer and certify the information above to be true to the best of my knowledge.^*