Volleyball Parent COVID-19 Form

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Please complete the following information (BOTH INDIVIDUALS ATTENDING MUST COMPLETE THEIR OWN FORM) before coming to the game.

Email *

Date of game *

YYYY

Todays Date *

YYYY

Student Last Name *

Student First Name *

Spectator's Full Name *

Spectator's Phone Number

Section 1: Symptoms

Any of the symptoms below could indicate a COVID-19 infection and may put you at risk for spreading illness to others. Please note that this list does not include all possible symptoms and individuals with COVID-19 may experience any, all, or none of these symptoms. Please check yourself for these symptoms on the day of your senior night:

Group A *

Fever (measured or subjective)

Chills

Rigors (shivers)

Myalgia (muscle aches)

Headache

Sore Throat

Nausea or Vomiting

Diarrhea

Fatigue

Congestion or runny nose

NONE of the above

Required

Group B *

Cough

Shortness of Breath

Difficulty Breathing

New loss of smell

New loss of taste

NONE of the above

Required

If TWO OR MORE of the fields in Group A are checked off OR AT LEAST ONE field in Group B is checked off, please stay home.

Section 2: Close Contact/Potential Exposure

Please verify if:

NONE of the below

You have had close contact (within 6 feet of a person who tested positive of COVID-19 for a total of 15 minutes or more over a 24 hour period.)

Someone in your household is diagnosed with COVID-19

You have traveled to an area of high community transmission.(CLICK LINK FOR DETAILS) https://covid19.nj.gov/faqs/nj-information/travel-and-transportation/are-there-travel-restrictions-to-or-from-new-jersey

Required

If ANY of the fields in Section 2 are checked, you should remain at home. Contact your local health department for further guidance.

A copy of your responses will be emailed to the address you provided.

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