Belmont Youth Hockey Survey
Please fill out survey in it's entirety.
I am a...
Your First Name
Your Last Name
Parent/Guardian completing this screening
You are attending what rink on this day?
Somerville - Founders
Somerville - Veterans
Today or in the past 24 hours, have you or any household members had any of the following symptoms? Fever (temperature of 100.0F or above), felt feverish, or had chills, Cough, Sore throat, Difficulty breathing, Gastrointestinal symptoms (diarrhea, nausea, vomiting), Fatigue, (Fatigue alone should not exclude a child from participation.) Headache, New loss of smell/taste, New muscle aches, Any other signs of illness?
In the past 14 days, have you had close contact with a person known to be infected with the novel coronavirus (COVID-19)?
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