Bethesda Premier Cup COVID-19 Pre-Screen Questionnaire

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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.

Full Team Name (FC Bucks Green 2009, Bethesda Blue 2008, etc.) *

Age Group *

Does any member of your team have a temperature of or about 100.4? *

Yes

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

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

Our team agrees to follow all social distancing rules as stipulated by the Premier Cup organizers. *

Yes

Name of COVID-19 Manager this Form (First and Last Name) *

Today's Date (DO NOT put your Date of Birth) *

YYYY

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