EIRA COVID-19 Symptoms Check

EIRA COVID-19 symptoms check

Submit 3-4 hours prior to an event
Parent Name *

First Name Last Name
Player Name *

First Name Last Name
Player Birth year *
Parent Cell # *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Parent Email *

Confirmation Email example@example.com
Actual Date *

Month Day Year
Date
Practice Date *

Month Day Year
Date
EIRA Event *
Parent - Please complete these questions on behalf of your participating son or daughter. Are you currently diagnosed with or believe you may have COVID-19? *
This applies to all members of the same household
Have you or your child had ANY of the following symptoms in the past 14 days (only check if you have). If you and your child 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 and your son/daughter 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? *
if you have then stay at home
Have you recently travelled to another state?

Street Address

Street Address Line 2
Should be Empty: