Attestation Form

Name*
First Last
Team*
Medical Privacy
It is against medical privacy laws for any business to make disclosure of medical information a stipulation of receiving service (in this case a private membership to NRS Sports leagues). NRS respects each person's right to medical privacy and does not discriminate.
Mandate
Ontario Health mandate requires us to ask for your vaccine status. While we respect medical privacy we are required to ask and if you answer "NO" you are not permitted to play. Please read everything carefully.
_
Have you received both covid vaccinations min 14 days ago or longer?*
- I prefer not to disclose my personal private medical information
- No
- Yes
Thank You
Undortunately, you are not permited to play.
Do you have any of the following?
- Fever Chills
- New cough or a cough that is getting worse
- Difficulty breathing
- Shortness of breath (even when sitting or walking regularly)
- Sore throat (not due to allergies)
- A runny or congested nose (not due to allergies)
- Unusual level of fatigue
- Unusual headache
- Nausea / vomiting, diarrhea, or loss of appetite
- Feeling unwell for an unknown reason
- Have you been in close contact with someone who is either sick, sent for testing, or has confirmed COVID-19 in the past 14 days?
- Have you returned from travel outside Canada in the past 14 days?
Check only boxes you are answering "Yes" to
Do you have any of the above symptoms?*
- No - I have read the screening tool and have none of the above symptoms today.
- Yes - I have one or more of the symptoms above
Unfortunately you are not eligible to play today. If you answered YES to any of the these questions, notify your workplace, go home and self-isolate right away. Call your health care provider or the COVID-19 Info-Line at 905-688-8248 and a public health professional will give you detailed instructions to follow to protect you, your family and members of the public. Novel Coronavirus (COVID-19) Info-Line Talk to a public health professional Monday to Friday from 9:15 a.m. to 8:30 p.m., and Saturday and Sunday from 9:15 a.m. to 4:15 p.m. 905-688-8248 press 7, then press 2 Toll-free: 1-888-505-6074
Congratulations you are eligible to play. Have fun at the game and if you experience any of the above symptoms please leave the game/ park and contact public health.
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