COVID - 19 Screening
This form must be completed prior to and each time you plan to attend practice or any skating session (or observe practice or skating session) at The Kiwanis Ice Arena
Email *
Player / Parent / Observer FIRST Name (1 survey per person) * *
Player / Parent / Observer LAST Name (1 survey per person) * *
Contact Number *
Coach's Name (If applicable)
Day of session you are attending/Practice /Game Date * *
1. Have you traveled to any of the states on the NYS Quarantine list in the past 10 days? * *
2. Have you tested positive for COVID-19 in the past 10 days? * *
3. Have you knowingly been in close contact in the past 10 days with anyone who has tested positive for COVID-19 or who has had symptoms of COVID-19? * *
4. Have you had any of these symptoms in the last 48 hours? (select all that apply) * *
If you indicated yes to questions 1-3, you can not return to the rink until you have quarantined for 10 days AND you are currently not experiencing any symptoms. If you are experiencing any of the symptoms listed in question 4, do not attend practice until cleared by a physician
A copy of your responses will be emailed to the address you provided.
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