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Bethesda Premier Cup COVID-19 Pre-Screen Questionnaire
In order to better maintain the safety of all members of the Premier Cup Community we are asking that all players take the following Pre-Screen Questionnaire before each game.
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* Indicates required question
Full Team Name (FC Bucks Green 2009, Bethesda Blue 2008, etc.)
*
Your answer
Age Group
*
Choose
Girls U13
Girls U14
Girls U15
Girls U16
Girls U17
Girls U18
Girls U19
Boys U13
Boys U14
Boys U15
Boys U16
Boys U17
Boys U18
Boys U19
Does any member of your team have a temperature of or about 100.4?
*
Yes
No
In the last 14 days has any member of your team had any of the following symptoms? Please check all that apply.
*
Cough
Trouble Breathing, shortness of breath, or wheezing
Chills or repeated shaking with chills
Muscle aches
Sore throat
Diarrhea
Loss of smell or taste or change in taste
Nausea, vomiting, or diarrhea
None of the above
Required
In the last 14 days, has your any member of your team been waiting for a COVID-19 test result, been diagnosed with COVID-19, or been instructed by any health care provider to isolate or quarantine?
*
Yes
No
In the last 14 days, has any member of your team had close contact (within 6 feet for at least 15 minutes) with anyone diagnosed with COVID-19 or suspected of having COVID-19 (i.e. tested due to symptoms)?
*
Yes
No
Our team agrees to follow all social distancing rules as stipulated by the Premier Cup organizers.
*
Yes
No
Name of COVID-19 Manager this Form (First and Last Name)
*
Your answer
Today's Date (DO NOT put your Date of Birth)
*
MM
/
DD
/
YYYY
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