Health Assessment Form
Please complete this form before the start of fall House League.

The form is to be completed for each child in the family. If you respond "Yes" to any statement, your child will not be permitted to participate in the fall House League for a period of 14 days.


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Player First Name *
Player Last Name *
Parent First Name *
Parent Last Name *
I, or another a member of my household is currently experiencing symptoms related to COVID-19 (cough, fever, trouble breathing, extreme fatigue, sore throat, sudden loss of taste or smell, purple fingers or toes). *
I or a member of my household has experienced a cold or flu-like symptoms within the last 14 days. *
I or a member of my household has had close contact with someone who has been diagnosed with COVID-19 within the last 14 days. *
I or a member of my household has travelled outside the country within the last 14 days. *
I or a member of my household has been in close contact with a person who has travelled outside the country within the last 14 days. *
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