INDIVIDUAL DAILY HEALTH DECLARATION FORM

Date: May 10, 2024

Submission for *

Parent and Player
Coach or Staff

Person submitting (Legal Guardian or Coach) *

First

Last

Player's Name *

First

Last

Program *

Please choose your participating program.

Phone *

Your phone number

Email *

Your e-mail address

I am confirming that NEITHER THE PLAYER, NOR MYSELF has or has had any of these symptoms in the last 14 days: *

Cough.
Fever Greater than 100°F.
Shortness of Breath.
Tested positive for COVID-19 in the past 14 days.
Been in close* contact with a confirmed or suspected COVID-19 case in the past 14 days.

*Per the CDC, a close contact is someone who was within 6 feet of an infected person for at least 15 minutes starting from 48 hours before illness onset until the time the patient is isolated.

Within the last 14 days, NEITHER THE PLAYER, NOR MYSELF has returned from a state on the NY/NJ/CT State Travel* Advisory List: *

I confirm

*NY/NJ/CT State Travel Advisory List currently lists following states: Alabama, Alaska, Arkansas, California, Delaware, Florida, Georgia, Guam, Hawaii, Iowa, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maryland, Minnesota, Missouri, Mississippi, Montana, North Carolina, North Dakota, Nebraska, Nevada, Ohio, Oklahoma, Puerto Rico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin.

Legal Guardian Declaration *

I declare that I am the official legal guardian of the above mentioned player entering L.I.C. Ice premises.

Accuracy Declaration *

I agree I have answered the questions on this form accurately, to the best of my knowledge.