Victoria Soccer Club - Self Assessment Health Questionnaire

Player First Name*

Guardian First Name

Player Last Name*

Guardian Last Name

Age Group

Home Phone*

Email*

Date of game*

Time of game

02:30 PM

Field*

Will you play today?

1. Does the player attending today's session have any of the below symptoms:

Fever*

Cough*

Shortness of Breath/Difficulty Breathing*

Sore throat*

Chills*

Painful swallowing*

Runny Nose/Nasal Congestion*

Itchy or Red Eyes (Conjunctivitis)*

Feeling Unwell/Fatigued (Tired)*

Nausea/Vomiting/Diarrhea*

Unexplained Loss of Appetite*

Loss of Sense of Taste or Smell*

Muscle/Joint Aches*

Headache*

2. Have you, or anyone in your household traveled outside of Canada in the last 14 days?*

3. Have you or your children attending the program had close unprotected contact (face- to-face contact within 2 metres/6 feet) with with someone who is ill with a cough/fever?*

4. Have you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or con rmed to be a case of COVID-19?*

If you have answered YES to any of these above questions you may not play today. Go home
and please use the AHS Online Assessment Tool to determine if testing is required.
Thank you so much for your help.

Your entry is confirmed

A required field is missing

Victoria Soccer Club - Self Assessment Health Questionnaire

1. Does the player attending today's session have any of the below symptoms:

If you have answered YES to any of these above questions you may not play today. Go home and please use the AHS Online Assessment Tool to determine if testing is required. Thank you so much for your help.

If you have answered YES to any of these above questions you may not play today. Go home
and please use the AHS Online Assessment Tool to determine if testing is required.
Thank you so much for your help.