COVID-19 Health Screening for Visiting Teams
This is a Pre-Game Screening for opponents of Lenape Valley Soccer Club.
If you are a Lenape Valley player, please complete our internal club form instead: https://forms.gle/DFwuP7WMT32cqV5a7
Sign in to Google to save your progress. Learn more
Please enter the player's first and last name. *
Please enter the parent's first and last name. *
What Club/Town does your child play for? (ex: Sparta Soccer Club) *
What is the Name and Age Group of the Team? (ex: U11 Rockets) *
What is the Player's Birth Year? (Year only) *
Enter the Date the Game will be played: *
MM
/
DD
/
YYYY
Was the player's temperature over 100.4 degrees Fahrenheit today? *
Has the player tested positive for COVID-19 within the last 14 days? *
Does the player have any of the following symptoms; Fever or Chills, Cough, Shortness of Breath or Difficulty Breathing, Fatigue, Atypical Muscle Pain or Body Aches, Headache, New Loss of Taste or Smell, Sore Throat, Congestion or Runny Nose, Nausea or Vomiting, and/or Diarrhea? *
Within the past 14 days, has the player traveled outside of the United States OR visited any of the states on the New Jersey Travel Advisory List (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) *
Within the last 14 days, has anyone in the player's household been exposed to, or come into contact with, anyone you know: (a) who has COVID-19, (b) who is/was being tested for COVID-19, (c) who had symptoms consistent with COVID-19, or (d) who was exposed to someone with COVID-19? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms