Health Screening Form

1
Name
First Name
Last Name
2
Date
Date
Year
Month
Day
3
Email
example@example.com
4
MNC Program
BKL Penguins
BKL Jackrabbits
BKL Arctic Foxes
BKL Racers
Juniors
Masters
5
SymptomsDo you have any of the following symptoms: fever, cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, fatigue, muscle or body aches, headache, congestion or runny nose, sore throat, new loss of taste or smell, nausea or vomiting, diarrhea?
YESNO
6
TemperatureIs your temperature above 100.4 F degrees?
YESNO
7
Close ContactIn the past 14 days, have you had close contact with a person confirmed to have COVID-19?
YESNO
8
QuarantineHave you traveled outside the state for any non-essential reason, which requires that you quarantine?
YESNO
9
If you answered "yes" to any questions above, please contact Coach Adam or Coach Rosemary and DO NOT attend MNC sessions until you have had further medical evaluation. Thanks!
Should be Empty: