NEXT PLAY 360 COVID - 19 ENTRY SCREENING
Please have all coaches and parents (for players) fill this form out prior to arriving to the gym.
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Email *
Today's date *
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Type your First Name and Last Name *
Cell Phone Number *
Select one *
Player Graduation Year
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What is the name of your team? *
Please answer yes or no. *
Yes
No
Have you had a fever of a 100.4 or greater within the last 72 hours? (Note: A "normal" temperature can range from 95.5 to 99.5 F)
Shortness of breath
Malaise/Aches
Chills
Loss of Taste
Cough
Sore Throat
Loss of Smell
Fatigue
Have you traveled to any domestic (within US) or international areas in the last 14 days?  YES or NO.  If so, where and when? *
Have you been around anyone who has traveled domestically or internationally with the last 14 days? YES or NO.   If so, where and when? *
Have you come into close contact with any individual experiencing COVID-19 symptoms or has been presumed positive or tested for COVID-19 symptoms or has been presumed positive or tested for COVID-19? Type YES or NO for your answer.   If so, who and when? *
Have you come into close contact with any individual experiencing flu-like symptoms? Type YES or NO for your answer.   If so, who and when? *
Have you ever been tested for COVID - 19?  YES or NO.  If so, when______?  Type results Positive or Negative *
If you tested positive for COVID - 19, what was the date of your positive test.  
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By clicking yes you agree to NEXT PLAY 360 media wavier/release statement:                                                         I give permission for my child to be photographed, videotaped and his/her information (such as stats, etc.) to be used in advertisement for NEXT PLAY 360° and its affiliates. This includes NEXT PLAY 360°, and its affiliate website, social media, newspaper etc. for positive promotion of the program. ALL SERVICES ARE NON-TRANSFERABLE AND NON-REFUNDABLE. *
By clicking yes you agree to NEXT PLAY 360 wavier/release statement:                                                        I consent and certify to release all liability from NEXT PLAY 360 and its affiliates as it pertains to my   attendance and participation in the tournament and any NEXT PLAY 360 event. I further release all liability including injury or exposure of COVID-19 from NEXT PLAY 360 and its affiliates.  I do hereby waive, release, absolve, indemnify and agree to hold harmless NEXT PLAY 360 and its affiliates for any and all claims arising out of injury to my child. *
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