Proteach Daily Health Screening Questionnaire

This questionnaire must be completed by each individual prior to participation in each club activity.

The answer to all questions must be “No” in order to participate in each club activity.

* Required

* Email Address:

* Please indicate the date of you or your child's upcoming visit:

* First and Last Name of Athlete:

* First and Last Name of Parent/Guardian filling out this form on behalf of the athlete:

* In the last 14 days, has the athlete (or any member of the household) had any of the following?:
Fever and/or chills Cough or worsening chronic cough Shortness of breath or other difficulties breathing Decrease or loss of sense of taste or smell Muscle aches/joint pain Extreme tiredness Sore throat Runny or stuffy/congested nose Headache Nausea, vomiting and/or diarrhea None of the above
* Has the athlete or any member of the household tested positive for COVID-19 in the past 14 days or have they been told they should be isolating?:
Yes No
* Did the athlete travel outside of Canada in the past 14 days? (answer No if the athlete is fully immunized and was not asked to self-isolate upon returning to Canada):
Yes No
* Has the athlete had close contact with a confirmed case of COVID-19 without wearing appropriate PPE in the past 14 days?:
Yes No
* If the answer is yes to any of the previous questions, I understand I will be asked to reschedule my class. In addition, if the athlete is just feeling sick with a cold or sore throat, please contact us to reschedule in order to keep our community healthy!:
Yes I understand
* Please be assured that Pro Teach has always met or exceeded the requirements set forth for sterilization and infection control, and will continue to do so. Pro Teach will provide socially distant class, and also has added a number of new technologies and techniques to enhance our level of safety. Please come to Pro Teach wearing your own mask and please come alone if possible. One parent or guardian will be allowed in Pro Teach with the athlete (please fill out a form for yourself if you will be attending the class). Please also remember to maintain physical distancing while at Pro Teach. We look forward to seeing you soon!:
Got it!
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Summary

If an individual answers "yes" to any of these questions, they are not permitted to participate in any club activities.

Please note: This Health Screening questionnaire has been developed based on the current Ontario Ministry of Health Self-Assessment Tool.