Bethesda Premier Cup COVID-19 Pre-Screen Questionnaire
In order to better maintain the safety of all members of the Premier Cup Community we are asking that all players take the following Pre-Screen Questionnaire before each game.
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Full Team Name (FC Bucks Green 2009, Bethesda Blue 2008, etc.)
Does any member of your team have a temperature of or about 100.4?
In the last 14 days has any member of your team had any of the following symptoms? Please check all that apply.
Trouble Breathing, shortness of breath, or wheezing
Chills or repeated shaking with chills
Loss of smell or taste or change in taste
Nausea, vomiting, or diarrhea
None of the above
In the last 14 days, has your any member of your team 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?
In the last 14 days, has any member of your team 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)?
Our team agrees to follow all social distancing rules as stipulated by the Premier Cup organizers.
Name of COVID-19 Manager this Form (First and Last Name)
Today's Date (DO NOT put your Date of Birth)
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