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

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