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MTK Summer Session COVID-19 Screening
Please complete the below questionnaire prior to your participation in any MTK activity and on the same day as the activity.
REMINDER – THIS FORM IS ONLY VALID IF COMPLETED ON THE DAY OF YOUR ACTIVITY.
A new form must be completed prior to each ACTIVITY, for each person entering the facility
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* Indicates required question
Email Address
*
Your answer
Name of Participant
*
Your answer
Role
*
Player
Coach / Trainer
Parent / Spectator
Parent/Guardian Name (if accompanying a minor)
*
Your answer
Phone Number
*
Your answer
Date
*
MM
/
DD
/
YYYY
Do you currently have any COVID-19 related symptoms? (fever, chills, cough, difficulty breathing, sore throat, runny nose, loss of taste/smell, diarrhea, nausea, vomiting, abdominal pain or nasal congestion)
*
Yes
No
In the last 14 days, have you had close physical contact with a person who was a confirmed or probable case of COVID-19?
*
Yes
No
By agreeing, I acknowledge that all information provided above is accurate and I have agreed to follow the policies and procedures put in place by MTK and the facilities upon entering the building.
*
I AGREE
I DISAGREE
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