JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
LES Health Screening
*PLEASE FILL THIS OUT HEALTH SCREENING BEFORE ENTERING PRACTICE. ALSO, PLEASE BE HONEST IF YOU ARE NOT FEELING WELL DO NOT COME TO PRACTICE.*
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Practice Facility
*
Choose
Indian River Intermediate School
Fairgrounds YMCA
Jefferson Community College
First Name
*
Your answer
Last Name
*
Your answer
Team Name
*
Choose
14-Silver
14-Ice
14-Storm
15-Blizzard
16-Silver
16-Ice
17-Ice
18-Storm
OTHER
Have you received a positive result from a COVID-19 test within the past 14 days?
*
Yes
No
In the past 14 days, have you been in close contact with anyone that has or had symptoms of COVID-19 that required you to quarantine?
*
Yes
No
Have you experienced a fever of 100.4 F or greater in the past 14 days?
*
Yes
No
In the past 14 days, have you experienced any of these symptoms that are attributed to another health condition: COUGH, LOSS OF SMELL OR TASTE, RUNNY NOSE, SHORTNESS OF BREATH, OR A SORE THROAT?
*
Yes
No
In the past 14 days, have you or someone you have been in close contact with traveled to an area that required quarantine upon return?
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Indian River Central School District.
Report Abuse
Forms
