Bethesda SC COVID-19 Pre-Screen Questionnaire

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In order to better maintain the safety of all members of the BSC Community we are asking that all players take the following Pre-Screen Questionnaire before each practice and game.

Player First Name *

Player Last Name *

Tryout Group *

Boys

Girls

Age Group *

Do you have a temperature of or about 100.4? *

Yes

In the last 14 days has your son/daughter 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 son or daughter 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 your child 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

Name of Parent/Legal Guardian Completing this Form (First and Last Name) *

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

YYYY

Submit

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