Chappaqua AYSO Participation Screening Form

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Everyone coming to a Chappaqua School District field must fill out the below form prior to attending each day and wear a mask at ALL times while on campus.

Parents should fill this out once for their player and once for themselves.

What is this person's role? *

Player

Coach

Trainer

Parent / Guardian / Chaperone

Other:

First Name *

Last Name *

Email Address *

Division *

Please read the following list of symptoms: Fever above 100F (37.8C)• Chills• Cough• Fatigue• Shortness of breath• Difficulty breathing• Muscle or body aches• Sore throat• New loss of taste or smell• Headache• Congestion or runny nose• Nausea or vomiting• Diarrhea *

No, I DO NOT have any of the listed symptoms

Yes, I have at least one of the listed symptoms

Have you tested positive for COVID-19 in the past 14 days? *

No, I HAVE NOT tested positive for COVID-19 in the past 14 days.

Yes, I have tested positive for COVID-19 in the past 14 days.

Have you been told to quarantine by a medical professional or Department of Health representative in the last 14 days? *

YES

Has anyone in your home been infected with the Coronavirus within the past 14 days? *

YES

Are you currently waiting for results for a COVID-19 Test taken because you suspect you may have been infected? (some employers require routine testing as a matter of course) *

YES

If you checked YES to any of the above questions, DO NOT participate in Chappaqua AYSO activities. Please contact your coach immediately and inform them of the situation.

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