Chappaqua AYSO Participation Screening Form
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?
Parent / Guardian / Chaperone
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?
Have you traveled in past 14 days to a US State or Country designated as high risk area by NYS/Federal Government?
Has anyone in your home been infected with the Coronavirus within the past 14 days?
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)
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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