Junior Squash COVID-19 Self-Screening

Once each week, before practice, please fill out the following for for your junior.

If you answer "Yes" to any of the questions below, please do not come to the Racquet Club.

Stay home if you are self isolating or contact Public Health if you are feeling ill.

Juniors's First and Last Name *

Today's Date *

Month

Day

Year

Parent's Email *

Have you, or anyone in your household traveled outside of the NWT in the past 14 days? *

Yes

Are you currently in self-isolation due to travel? *

Yes

Have you, or anyone in your household, been in contact in the last 14 days with someone that is being investigated for or confirmed to have COVID-19? *

Yes

Have you, or anyone in your household, been instructed to self-isolate? *

Yes

Do you have any ONE of the following symptoms? *

1. Fever
2. New or worsening cough
3. Shortness of breath

Yes

Do you have TWO or more of any of the following symptoms? *

1. Sore throat
2. Runny nose
3. Nausea/vomiting
4. Diarrhea
5. Headache
6. Feeling generally run down or tired
7. New loss or decrease in sense of smell or taste
8. Body aches

Yes

Any comments or other information

If there is anything else we need to know or would like to clarify a response, please add it here.

Tel 867.920.2224 • Fax 867.920.2480 • 4002-49th Avenue • Yellowknife, Northwest Territories X1A 2N4 CANADA