Coronavirus Questionnaire- Required EVERY VISIT by SKATERS, PLAYER, and SPECTATORS
This form must be completed by each parent, spectator, visitor and/or skater for every visit to Casey Park Ice Rink in order to enter the building. If you answer YES to any of these questions, please notify us immediately and seek advice from your physician. If you answered YES to any of these questions or not not agree with the contents, please DO NOT ENTER the rink. The information collected on this from will be used to determine only whether you may be infected with COVID-19 and pose a risk to other skaters, staff, and/or coaches. The information on this form will be maintained as confidential.

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Name of person entering the building- PLEASE complete one form for EACH player and EACH spectator- MUST BE 18 YEARS OLD or OLDER TO COMPLETE. *
Please choose ONE: *
Have you or a member of your immediate family tested positive for COVID in the past 10 days? *
In the past 10 days, have you tested positive through a diagnostic test, for COVID-19? *
In the past 10 days, have you travelled internationally or to a CDC level 2 or higher country or to any state other than Vermont, Massachusetts, Pennsylvania, New Jersey, or Connecticut? *
In the past 10 days, have you experienced any of the following symptoms of COVID-19? *
Cough, fever, headache, nausea, diarrhea
Shortness of breath or difficulty breathing
Muscle or body aches
Sore throat, loss of taste /smell
If you answered YES to any of these questions, do not enter the rink without pre-approval from our management team (email I hereby certify that the responses provided above are true and accurate to the best of my knowledge. *
COVID RELEASE- The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of group of people. Casey Park and the Auburn Hockey Club have put into place preventative measures to reduce the spread of COVID-19; however, Casey Park and the Auburn Hockey Club cannot guarantee that you or your participants, including child(ren) will not become infected with COVID-19. Further attending Casey Park could increase your risk and your participants' (including children) risks of contracting COVID-19. By clicking I AGREE, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by attending Casey Park and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I understand the risk of becoming exposed to or infected by COVID-19 at Casey Park may result from the actions, omissions, or negligence of myself and other, including, but not limited to, Casey Park employees, volunteers, and program participants and their families. *
I understand this data will be shared with rink administration as well as other people involved in the rental of the ice at the facility. By clicking I AGREE, I authorize you to share this information. *
By clicking I AGREE below, you agree that if any of your answers to the above questions change to a YES between the time you fill out this form and the time in which you arrive to Casey Park Ice Rink, you will NOT enter the facility and will notify Casey Park and Auburn Hockey Club personnel. This applies to any future planned visit to Casey Park Ice Arena. *
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