New Providence Soccer Club
COVID-19 Health Questionnaire for U13GIRLS team PRIDE
Thank you for helping New Providence Soccer Club with our COVID-19 procedures and for helping to keep our kids safe. Before each event (practice or game), your coach will email or message you with a link to this form. Please fill out this form no earlier than 8 hours before and no later than 1 hour before each event. Answer all of the questions in order to clear your child for play. If you answer "yes" to any of these questions we ask that you keep your child at home and return only when you can answer each of these questions with a "no". In the event that your child or someone in your household receives a positive COVID-19 test, please contact us at covidtracking@npsoccerclub.org.
Participant’s Name (Child) *
Please provide a phone number for someone we should contact if your child needs to be picked up from the event (practice or game) *
In the last 14 days, have you/participant (a) exhibited/experienced symptoms of COVID-19, or (b) been diagnosed with/tested positive for COVID-19? *
In the last 14 days, have you/participant been in close contact with anyone: (a) who exhibited/experienced symptoms of COVID-19, or (b) who was diagnosed with/tested positive for COVID-19? *
Have you/participant had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt “feverish”, or had a temperature that is elevated for you or 100.4F or greater? *
In the past 24 hours, have you/participant experienced the following unrelated to seasonal allergies: Fever, Loss of taste or smell, Aches and pains, Runny/stuffy nose, Shortness of breath, Nausea or vomiting, Cough, Sneezing, Sore throat, Diarrhea, Headaches or Fatigue? *
In the last 10 days (or 7 days with a negative test) have you/participant traveled internationally or outside of New Jersey (other than to New York, Pennsylvania, Connecticut, and Delaware) *
Regardless of how you answer the questions provided in this survey, if you have symptoms consistent with COVID-19 or feel you may be developing symptoms consistent with COVID- 19, you cannot attend or participate in any youth soccer activities and should contact a local healthcare professional.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy