NYC Skyliners Coronavirus Daily Health Declaration Form
For the health and safety of our organization, declaration of illness and symptoms are required each time you come to City Ice Pavilion. Be sure that the information below is accurate and complete, and that players and guardians BOTH fill out their own form prior to any Skyliners practice.
Name
*
First Name
Last Name
Team
*
Example: Squirt AA, Bantam A
Date/Time of Practice
*
Example: 9/12 7:30
Are you a parent or guardian?
*
Yes
No
Have you travelled to a hot-spot state in the past 2 weeks?
*
Yes
No
Name of the area(s) visited
*
Country, State, City
Dates of travel
*
Arrival and return dates for each area
Have you been exposed or possibly exposed to anyone infected with Covid-19?
*
Yes
No
Please state whether you've experienced/are experiencing any of the following
*
Yes
No
Fever over 100
Cough
Shortness of Breath
Persistent Pain in the Chest
I acknowledge that the information I've given is accurate and complete.
Date
*
-
Month
-
Day
Year
Date
Save
Submit
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