Required fields are marked with asterisks (*)

Twin Centre Stars and Hericanes Players Only COVID-19 Screening

As part of our commitment to providing a safe and healthy community, this recreation facility screening is required for entrance to the facility. Your answers will be used to generate a pass/fail response, which may be shared with the Township of Wellesley. Thank you for providing honest answers. Together, we are doing our part to ensure a safe community and minimize the spread of COVID-19.

Enter Participants Name

Participants Telephone Number including area code

Parent/Guardian/Caregiver Name (optional)

Parent/Guardian/Caregiver Phone Number (optional)

User Group

Facility

Date you are attending the facility

Scheduled time of use

How old are you?

17 yeas old or younger

18 years old or older

Do any of the following apply to you?

I am fully vaccinated against COVID-19 (it has been 14 days or more since your final dose of either a two-dose or a one-dose vaccine series)

I have tested positive for COVID-19 in the last 90 days (and since been cleared)

Are you currently experiencing any of these symptoms? Choose

Fever and/or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)

Cough or barking cough (croup) (Continuous, more than usual, making a whistling noise when breathing, not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

Shortness of breath (Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

Decrease of loss of taste or smell (Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have)

Muscle aches/joint pain (Unusual, long-lasting , not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Extreme tiredness (Unusual, fatigue, lack of energy, not related to getting a COVID019 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

None of the above

In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)?

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? (If you have since tested negative on a lab-based PCR test, select "No."

Yes

If you are experiencing symptoms or answered YES to any of the questions above, we ask that you please do not enter the facility.

If you answered NO to the questions above, you may enter the facility. We kindly ask that you practice the following health and saftey tips while inside the facility:

Keep a distance of at least 2 metres from people you do not live with
Make sure you wear a face covering or mask while indoors (and outdooes when you cannot physically distance) and that it covers your mouth, nose, and chin
Wash or sanitize your hands often

Statement

I hereby certify that the above information is accurate to the best of my knowledge.

To the extent that the foregoing information constitutes personal information as defined by the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. Chapter M.56, as amended, the information is subject to provisions of that Act and will be used exclusively by the Recreation Department of the Corporation of the Township of Wellesley and the applicable user groups for contact tracing purposes related to Covid-19. Questions about the collection of personal information should be directed to the Clerk, Township of Wellesley, 4639 Lobsinger Line, St. Clements, ON N0B 2M0.

The user agrees to hold and save harmless The Township of Wellesley for any actions, claims or proceedings for injuries, illness, damages, personal loss or other loss, caused by the negligence of the user during the use of the facility.

Form Builder

Twin Centre Stars and Hericanes Players Only COVID-19 Screening