PCMLA Health Check - Port Coquitlam Minor Lacrosse Association

COVID-19 Health Check

Please complete and submit the following mandatory COVID-19 Health Check on the day of, and prior to the PCMLA event you are attending.

Players Name

Phone

Reporting / Event Date

Date you are attending a Port Coquitlam Minor Lacrosse Event YYYY-MM-DD

Are you sick with a cold/flu or are you displaying any signs of COVID-19 and/or flu-like symptoms?
Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?
Have you travelled outside of the country within the last 14 days?
Have you been identified by Public Health as a close contact of someone with COVID-19?
Have you been told to isolate by Public Health in the last 14 days?

I acknowledge that I am required to wear a face mask in all areas of the facility, unless otherwise permitted by a Health Official.

Please refer to your facility's Covid Safety Plan for more details, found at COVID-19.

Payment

Discount

Subtotal

Tax

Total USD