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2021 Winter Clinic Admittance Ticket
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Email
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Your email
Today's Date
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MM
/
DD
/
YYYY
Player first name
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Your answer
Player last name
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Your answer
Clinic attending
10th - 12th - Monday
9th - Monday
8th - Wednesday
7th - Wednesday
6th -Tuesday
3rd/4th/5th - Tuesday
Other:
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Temperature prior to practice
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Your answer
Does the player live in the same household with someone who has tested positive for COVID-19 in the last 14 days?
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Yes
No
Has the player or anyone in the family (household) been in close contact with someone who has tested positive for COVID-19 in the last 14 days?
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Yes
No
Have you travelled outside of New Jersey or the USA?
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Yes
No
If yes, where did you travel? When did you return?
Your answer
Has the player exhibited any of the following symptoms today (or within the last 24 hour) which cannot be better explained by another condition. If no, check no symptoms; if yes, check those that apply:
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NO SYMPTOMS
Fever
Cough
Sore Throat
Shortness of Breath
Repeated shaking or shivering
Unusually weak/fatigued
Loss of taste or smell
Muscle aches or pain
Runny/congested nose
Diarrhea
Required
Please provide additional information if symptoms present are better explained by another condition (e.g. exercise induced muscle soreness, diagnosed seasonal allergies).
Your answer
I understand that if my daughter is experiencing any of the above symptoms prior to practice, without an explanation not related to possible COVID-19, the player is required to STAY HOME from practice until symptom free.
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Yes
I certify to the best of my knowledge; this information is accurate.
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Yes
Parent name/signature
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Your answer
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