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Covid NJSIAA Questionnaire
Girls Volleyball and Wrestling
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了解详情
* 表示必填
Name of Student
*
您的回答
ID #
您的回答
Grade
*
9
10
11
12
Date of Birth
*
年
/
月
/
日
Student Email
*
您的回答
Gender
*
Male
Female
Sport / Activity
*
Girls Volleyball
Wrestling
Parent / Guardian Name
*
您的回答
Parent / Guardian Cell Number
*
您的回答
Parent / Guardian Email
*
您的回答
Has your son/daughter been diagnosed with Coronavirus (COVID-19)?
*
Yes
No
If diagnosed with Coronavirus (COVID-19) was your son/daughter symptomatic?
*
Yes
No
Not applicable
If diagnosed with Coronavirus (COVID-19) was your son/daughter hospitalized?
*
Yes
No
Not applicable
Has any member of the student-athlete's household been diagnosed with Coronavirus (COVID-19) ?
*
Yes
No
Does your son/daughter have any pre-existing medical conditions or are immunocompromised ( such as diabetes, asthma, auto-immune disorders, etc)?
*
Yes
No
If yes, what condition?
您的回答
Has your son/daughter traveled out of state in the last 14 days?
*
Yes
No
If yes, what state?
您的回答
Date returned from out of state travel
年
/
月
/
日
Signature of Parent
*
By printing your name below and submitting this form you acknowledge that all information is correct. Your digital signature and date will be recorded with submission.
您的回答
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