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AVVC Daily Practice Covid-19 Questionnaire
To participate in workouts during the 2020-2021 club season, each player must complete this form before
every practice. The screening questionnaire must be completed prior to arriving at the training complex.
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Name of player *
Today's Date *
MM
/
DD
/
YYYY
Parent/Guardian Cell *
Teams *
Are you experiencing any of the following symptoms? *
Yes
No
Fever (≥ 100.4°F)
Cough or shortness of breath
Sore Throat
Chills
Muscle aches or rigors
Headache
New loss of taste or smell
Abdominal pain, nausea, vomiting or diarrhea
Have you had close contact with someone who is currently sick? *
Have you been diagnosed with COVID-19 in the past three weeks or have reason to believe you have COVID-19? *
Have you traveled or had close contact with anyone who has traveled internationally in the last 14 days? *
If you took your temperature this morning, what was the reading?
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