COVID-19 Health Screening Questionnaire
All individuals entering the facility are required to complete the below COVID-19 screening questionnaire prior to entering the facility.
Last Name of Player / Visitor
First Name of Player / Visitor
Goalie Parent (request temporary access at check-in)
Player Parent (request temporary access at check-in)
Health Screener (Required to stay and monitor lobby during entire practice)
SCRF (Ice Rink)
SCRF Parking Lot (Dryland)
Team Name, if applicable
8u (Kyle Youlen)
Mini-Mites / 8u (Peretti)
Rec Hockey (Brinker)
10u-AA (C. Youlen)
14u (J. Beck)
1. Is your temperature greater than 100.0 degrees
2. Do you have any signs of sickness (e.g., fever or chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, diarrhea)
3. Have you tested positive for COVID-19 or come into contact with someone that tested positive COVID-19 in the past 14 days
4. Are you currently under quarantine due to COVID-19 exposure
5. Are you returning from travel to any of the states listed on the NYS quarantine list
If you indicated "Yes" to any of questions 1-5, you cannot return to the rink until the 14-day quarantine period has ended. If you have any symptoms listed in question 2, do not attend practice until cleared by a physician. Contact Greg Marcincuk (firstname.lastname@example.org / 518.366.3147) or Brian Gregoire (email@example.com / 518.312.6695)
A copy of your responses will be emailed to the address you provided.
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