PJHA COVID 19 Screening Form-10U Group

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Participants and spectators will be required to answer the questions stated below before coming to the rink for any PJHA session. This form will also be able to be accessed via a QR code posted on the entrances to Pine Street Arena.
Should any individual (participant or spectator) answer “yes” or have a temperature above 100.4 will NOT be allowed to come to the rink today and will need to follow their physician’s recommendations for when it is safe to return to activity or be a spectator at Pine Street Arena.
This form is for both practices and games. By completing this form, parents, spectators, and players accept all risks associated with Covid-19 and play and enter at their own risk.

Please list name (first and last) of PARTICIPANT(s) at today's PJHA session. *

Please list name(s) (first and last) of SPECTATOR(s) (MAX 2) who will be in the rink for today's PJHA session. *

If you are an on-ice coach or game volunteer for this session , please write your first and last name.

1. Have you or anyone in your household had a sore throat, cough, chills, body aches, shortness of breath, loss of smell, loss of taste, diarrhea, vomiting, fever at or greater than 100 degrees Fahrenheit in the last 10 days? *

Yes

2. Have you or anyone in your household been tested for COVID-19 due to contact and/or symptoms and awaiting results or tested positive requiring mandatory quarantine per NYSDOH guidelines? NOTE: EXCLUDES routine tests required for employment and/or student-athletes. *

Yes

3. To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19 OR been contacted by NYSDOH requiring mandatory quarantine? *

Yes

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