EIRA COVID-19 symptoms check
Submit 4 hours prior to an event. If you are feeling sick do not attend
Parent Name
*
First Name
Last Name
Player Name
*
First Name
Last Name
Player Birth year
*
2002
2003
2004
2005
2006
2007
2008
2009
2010
Staff
Staff select 'staff'
Parent Cell #
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent Email
*
Confirmation Email
example@example.com
Actual Date
*
-
Month
-
Day
Year
Date
Practice Date
*
-
Month
-
Day
Year
Date
EIRA Event
*
Carolinas Academy
Heartland Academy
So Cal Academy
Other event
Are you currently diagnosed with or think you might have COVID-19?
*
Yes
No
This applies to all members of the same household
Have you had ANY of the following symptoms in the past 14 days. If you are symptoms free then check symptoms free
*
High temperature (fever)
Chills
New unexplained shortness of breath
Sore throat and or cough
Muscle or body aches (not from exercise)
Headache
Loss of taste or smell
Diarrhea
Congestion or runny nose
Nausea or vomiting
If you are symptom free check here
Have you or your child been in contact with a COVID-19 confirmed or suspect case in the previous 14 days?
*
Yes
No
if you have then stay at home
Have you recently travelled to another state?
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Submit
Should be Empty: