BYHA Covid-19 Questionnaire
This questionnaire must be completed for all players and coaches every session/each day before they will be allowed on the ice. Complete this COVID-19 health questionnaire no fewer than 2 hours prior to practice/game. If your skater is experiencing COVID-19 related symptoms contact BYHA President-Lena Gawtry immediately and we ask that you keep your skater home to protect others. Please contact Lena if you have any COVID-19 related questions.
Lena's contact information: 612-386-1104 or
I am checking in the following people ... (please check all that apply).
Group affiliation for this ice session (please check all levels that apply).
Mini-Mites / 6U
Mites / 8U
First Name (Player/Coach/Fan/Volunteer)
Last Name (Player/Coach/Fan/Volunteer)
If checking in multiple people, please list out ALL of the first names of the people in your group.
Parent/Guardian Email Address
Parent/Guardian Phone Number
Rink Location for this Day
Purple Rink (New Rink)
If "other" was listed for location, please specify location:
Do you have any of the following COVID-19 Symptoms: *Fever of 100.4 or higher 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 *
Fever (100.4 or greater), or a sense of having fever/feeling feverish (chills,sweating)
A new cough
A new shortness of breath
A new sore throat
New muscle aches that are not caused by a specific activity (such as a physical exercise)
None of the above
Have you had close contact with or cared for someone diagnosed with COVID-19 in the past 14 days?
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This form was created inside of Buffalo Youth Hockey Association.