COVID-19 Parent and Child Self-Screening Form

The safety of young players, their parents and our employees, remains Pro-Ambitions’ primary concern. As the coronavirus (COVID-19) outbreak continues, Pro-Ambitions is monitoring the situation closely and will periodically update our policies and procedures based on current recommendations from the Center for Disease Control and health and safety authorities in state and local governments. To help prevent the spread of COVID-19 and reduce the potential risk of exposure to children, parents and employees, we are conducting a simple screening questionnaire upon your arrival at the rink. Your participation is important to help us take precautionary measures to protect your child and all other young players and everyone else in the rink facility. Thank you for your understanding and cooperation.

I am the*

Name of Parent/Legal Guardian*

Email*

Best Contact Number*

Child's Name(s) and Age(s):*

Home Address*

If the answer to question 1 or 2 below is yes, access to the rink facility will be denied.

1. Have you, your child or anyone else in your immediate family within the past 14 days been diagnosed with COVID-19 or had contact with someone diagnosed with COVID-19?*

2. Are you, your child or anyone else in your immediate family showing any signs of one or more of the following symptoms? Temperature of 100.4 °F or higher, chills, cough, shortness of breath, difficulty breathing, runny nose, sore throat, new loss of taste or smell, muscle pain, or tiredness?*

3. If my child experiences, or is believed by Pro Ambitions’ staff to be experiencing any of the symptoms set forth above in Question No. 2, while attending Camp, we will promptly depart the rink and not return. 4. Is the information you provided on this form true and correct to the best of your knowledge?*

Date*

Are you human?*

This field should be left blank