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COVID - 19 Screening
This form must be completed by each participant and spectator prior to and each time you plan to attend practice/game.
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* Indicates required question
Email
*
Your email
Player / Parent / Observer FULL Name (1 survey per person, please) *
*
Your answer
Contact Number
*
Your answer
Age Group
6U
8U
10U
12U
School Yard
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Orientation/Practice Date
*
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/
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1. Have you traveled internationally in the past 14 days?*
*
Yes
No
2. Have you tested positive for COVID-19 in the past 14 days? *
*
Yes
No
3. Have you knowingly been in close contact in the past 14 days with anyone who has tested positive for COVID-19 or who has had symptoms of COVID-19?*
*
Yes
No
4. Have you had any of these symptoms in the last 48 hours? (select all that apply) *
*
Cough
Chills
Shortness of breath or difficulty breathing
Nausea or vomitting
Fever
Muscle Pain
Sore Throat
Diarrhea
Loss of taste or smell
None
Required
*If you indicated yes to questions 1-3 you cannot return to the field until the 14 day quarantine period has ended. If you have any symptoms listed in question 4, do not attend practice until cleared by a physician.
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