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.
Email address *
Last Name of Player / Visitor *
First Name of Player / Visitor *
Visitor Description *
Event Location *
Event Type *
Team Name, if applicable *
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 (gmarcincuk@gmail.com / 518.366.3147) or Brian Gregoire (bgregoire19@hotmail.com / 518.312.6695)
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy