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

Are you fully vaccinated against COVID-19 (2 doses) if over the age of 12?

Yes

In the last 5 days, have you experienced: fever or chills, cough or barking cough, shortness of breath, decrease or loss of taste/smell, muscle aches/joint pain, extreme tiredness, sore throat, runny/congested nose, headache, nausea, vomiting, diarrhea?

Yes

In the last 14 days, have you travelled outside of Canada and been told to quarantine?

Yes

Has a doctor, health care provider, or public health told you that you should currently be isolating?

Yes

In the last 5 days, have you tested positive for COVID-19?

Yes

Do you live with someone who is currently isolating because of a positive COVID-19 test, COVID-19 symptoms, or awaiting COVID-19 test results?

Yes

In the past 5 days, have you been identified as "close contact" of someone who currently has COVID-19 or symptoms of COVID-19?

Yes

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.

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Twin Centre Stars and Hericanes Players Only COVID-19 Screening