New Providence Soccer Club

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COVID-19 Health Questionnaire for U11 Boys team REAL

Thank you for helping New Providence Soccer Club with our COVID-19 procedures and for helping to keep our kids safe. Before each event (practice or game), your coach will email or message you with a link to this form. Please fill out this form no earlier than 8 hours before and no later than 1 hour before each event. Answer all of the questions in order to clear your child for play. If you answer "yes" to any of these questions we ask that you keep your child at home and return only when you can answer each of these questions with a "no". In the event that your child or someone in your household receives a positive COVID-19 test, please contact us at covidtracking@npsoccerclub.org.

Participant’s Name (Child) *

Please provide a phone number for someone we should contact if your child needs to be picked up from the event (practice or game) *

In the last 14 days, have you/participant (a) exhibited/experienced symptoms of COVID-19, or (b) been diagnosed with/tested positive for COVID-19? *

Yes

In the last 14 days, have you/participant been in close contact with anyone: (a) who exhibited/experienced symptoms of COVID-19, or (b) who was diagnosed with/tested positive for COVID-19? *

Yes

Have you/participant had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt “feverish”, or had a temperature that is elevated for you or 100.4F or greater? *

Yes

In the past 24 hours, have you/participant experienced the following unrelated to seasonal allergies: *

Yes

Fever

Loss of taste of smell

Aches and Pains

Runny / Stuffy Nose

Shortness of Breath

Nausea or Vomiting

Cough

Sneezing

Sore Throat

Diarrhea

Headaches

Fatigue

In the last 10 days have you/participant traveled internationally or to any of the states on the NJ travel advisory list (list can be found at https://covid19.nj.gov/faqs/nj-information/travel-and-transportation/which-states-are-on-the-travel-advisory-list-are-there-travel-restrictions-to-or-from-new-jersey)? *

Yes

Regardless of how you answer the questions provided in this survey, if you have symptoms consistent with COVID-19 or feel you may be developing symptoms consistent with COVID- 19, you cannot attend or participate in any youth soccer activities and should contact a local healthcare professional.

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