Skater's/Coach's Name *

Please enter name of the skater/coach attending Practice.

First Name

Last Name

Date *

Today's Date

MM

DD

YYYY

Fever (100.4 degrees F or higher) or Chills *

Yes

No

Fatigue *

Yes

No

Cough *

Yes

No

Shortness of Breath *

Yes

No

Muscle or Body Aches *

Yes

No

Congestion or Runny Nose *

Yes

No

Sore Throat *

Yes

No

Diarrhea *

Yes

No

Headaches *

Yes

No

Loss of taste or smell *

Yes

No

Nausea or Vomiting *

Yes

No

Has the skater had contact with someone who has tested positive for COVID-19 or who is awaiting test results? *

Yes

No

Has the skater traveled outside Pennsylvania during the last fourteen (14) days? *

Yes

No

If the skater has traveled outside Pennsylvania in the last 14 days, has the skater received a negative COVID-19 test within 72 hours of returning to Pennsylvania or has the skater quarantined for 14 days? *

Please refer to CDC website for situations whereby this requirement in not applicable. https://www.health.pa.gov/topics/disease/coronavirus/Pages/Travelers.aspx

Yes

No

N/A

I am following ALL CDC recommended guidelines limiting my skater's exposure to risks such as stated above. *

Yes

No

If my skater has any symptoms (or had them in the past 14 days), I will keep him/her home from practice until I have a doctor's note providing clearance for my skater to return to practice. *

Yes

No