Covid NJSIAA Questionnaire
Girls Volleyball and Wrestling
Name of Student *
ID #
Grade *
Date of Birth *
MM
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DD
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Student Email *
Gender *
Sport / Activity *
Parent / Guardian Name *
Parent / Guardian Cell Number *
Parent / Guardian Email *
Has your son/daughter been diagnosed with Coronavirus (COVID-19)? *
If diagnosed with Coronavirus (COVID-19) was your son/daughter symptomatic? *
If diagnosed with Coronavirus (COVID-19) was your son/daughter hospitalized? *
Has any member of the student-athlete's household been diagnosed with Coronavirus (COVID-19) ? *
Does your son/daughter have any pre-existing medical conditions or are immunocompromised ( such as diabetes, asthma, auto-immune disorders, etc)? *
If yes, what condition?
Has your son/daughter traveled out of state in the last 14 days? *
If yes, what state?
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.
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