Belmont Youth Hockey Survey

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out survey in it's entirety.

I am a... *

Your First Name *

Your Last Name *

Parent/Guardian completing this screening

You are attending what rink on this day? *

Team *

Today or in the past 24 hours, have you or any household members had any of the following symptoms? Fever (temperature of 100.0F or above), felt feverish, or had chills, Cough, Sore throat, Difficulty breathing, Gastrointestinal symptoms (diarrhea, nausea, vomiting), Fatigue, (Fatigue alone should not exclude a child from participation.) Headache, New loss of smell/taste, New muscle aches, Any other signs of illness? *

Yes

In the past 14 days, have you had close contact with a person known to be infected with the novel coronavirus (COVID-19)? *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms