Roselle Park Soccer Club                                                Player Covid-19 Self Screening Questionnaire
This form must be completed before each practice/training and each game/scrimmage.

Should you answer "YES" to any of the below questions, your child should NOT attend the practice/training/game/scrimmage and before they return, should follow appropriate medical advice and guidelines.

By submitting this form, you certify to the best of your knowledge; this information is accurate.
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Email *
1) Has the player had any of the following symptoms in the last 24 hours? *
Yes
No
Fever (100.4) or higher
Chills
Repeated shaking with chills
Muscle pain
Headache
Soar throat
Cough
Shortness of breath and difficulty breathing
New loss of taste or smell
If you answered “Yes” to question one,  DO NOT attend this weeks' practice/training/game/scrimmage and you should:                                                                              
Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
Improved respiratory symptoms (no cough, shortness of breath)
2) In the last 14 days has the player: *
Yes
No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled outside of these 5 states NJ, NY, CT, PA or DE?
If you answered “Yes” to any part of question two DO NOT attend this week's  practice/training/game/scrimmage. You should self quarantine for at least 10 days.
Player Name *
Team Name and Coach Name *
Parent Name and Cell# *
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