Please complete this form in its entirety. Bring the email confirmation with you to the Recreation Centre to show staff.

Which location will you be visiting? *

Select Pre-Registered Activity. *

If part of a community group please select it below.

Date Of Activity
According to public health directives, this form must be completed on the day of the activity. If your activity is in the future, please return to complete this form on that day.

Start Time *

Participant Screening Questions

The following information pertains to the participant and the adult/guardian submitting the form.

Do you have any of the following new or worsening symptoms or signs?

Fever or chills

Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Cough or barking cough (croup)

Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have
Difficulty breathing or shortness of breath

Not related to asthma or other known causes or conditions you already have

Decrease or loss of smell or taste
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
Nausea, vomiting, diarrhea (under 18 years)
Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have
Extreme tiredness or muscle aches (18 years or older)
Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.”

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
This can be because of an outbreak or contact tracing.

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?
If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized* or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.”

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?
If you have already gone for a test and got a negative result, select "No." If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No."

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

In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements) in the last 14 days?
If you are fully immunized or have tested positive for COVID-19 in the last 90 days andsince been cleared, select “No.”

In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate in the last 10 days?
If you are fully immunized or have tested positive for COVID-19 in the last 90 days andsince been cleared, select “No.”

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
If the individual experiencing symptoms received a COVID-19 vaccination in the last 48hours and is experiencing mild fatigue, muscle aches, and/or joint pain that onlybegan after vaccination, select “No.” If you are fully vaccinated or have tested positive for COVID-19 in the last 90 days andsince been cleared, select “No.”

Do any of the above listed symptoms, or conditions apply to you? Yes No

The personal information collected through this form is collected under the authority of the Municipal Act, 2001, Section 8. The information will be used to screen you and all participants accompany you for COVID-19 risk factors prior to entering the City facility. In the event of a confirmed COVID-19 diagnosis that coincides with your visit to a City facility or participation in a City program, your name and contact information may be provided to public health authorities for purposes of contact tracing. Questions about the collection should be directed to Director of Recreation & Culture, 705-739-4287, recreation.information@barrie.ca.