Covid NJSIAA Questionnaire
Girls Volleyball and Wrestling
* Required
Name of Student
*
Your answer
ID #
Your answer
Grade
*
9
10
11
12
Date of Birth
*
MM
/
DD
/
YYYY
Student Email
*
Your answer
Gender
*
Male
Female
Sport / Activity
*
Girls Volleyball
Wrestling
Parent / Guardian Name
*
Your answer
Parent / Guardian Cell Number
*
Your answer
Parent / Guardian Email
*
Your answer
Has your son/daughter been diagnosed with Coronavirus (COVID-19)?
*
Yes
No
If diagnosed with Coronavirus (COVID-19) was your son/daughter symptomatic?
*
Yes
No
Not applicable
If diagnosed with Coronavirus (COVID-19) was your son/daughter hospitalized?
*
Yes
No
Not applicable
Has any member of the student-athlete's household been diagnosed with Coronavirus (COVID-19) ?
*
Yes
No
Does your son/daughter have any pre-existing medical conditions or are immunocompromised ( such as diabetes, asthma, auto-immune disorders, etc)?
*
Yes
No
If yes, what condition?
Your answer
Has your son/daughter traveled out of state in the last 14 days?
*
Yes
No
If yes, what state?
Your answer
Date returned from out of state travel
MM
/
DD
/
YYYY
Signature of Parent
*
By printing your name below and submitting this form you acknowledge that all information is correct. Your digital signature and date will be recorded with submission.
Your answer
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