EJYH COVID-19 Screening Questionnaire
This screening form is REQUIRED to be completed, per individual, NO MORE THAN 24 HOURS prior to your scheduled event time at the First Arena rink.

If any question is answered "yes," or if you have a temperature above 100.0, entry WILL NOT be permitted to the First Arena rink, today, and it is advised you follow up with your health care provider.

Temperatures and Screening compliance will be checked at the door, prior to allowing entry to the rink.
Email address *
Date of your EJYH Event: *
Full Name of Person attending today's event: *
The person attending today's event is a: *
This event is for: Select Age Level and EJYH Team (Blue/White/Red) - If you are not part of EJYH, select the team you will be interacting with. *
Phone Number - Use Parent/Guardian Phone Number if form entry is for a player. *
Is your temperature above 100.0 Deg F? *
Do you currently have (or have you had in the past 10 days) one or more of these new or worsening symptoms: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea? *
In the past 10 Days, have you tested positive for COVID-19 or have you been tested for COVID-19 and you are still waiting for the result? *
In the past 14 Days have you been designated a contact of a person who tested positive for COVID-19 by a local health department? *
Have you traveled outside NY to a non-contiguous State, or territory, or a CDC level 2 and higher country working the past 14 days? *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy