COVID-19 Screening Form-Youth
Midstate Youth Rugby
Player Name *
School you attend: *
Have you experienced any of the following symptoms in the past 48 hours? *
Have you been in close physical contact in the last 14 days with: *
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are you worried that you may be sick with COVID-19? *
Are you currently waiting on the results of a COVID-19 test? *
Have you traveled in the past 10 days? Travel is defined as any trip that is overnight AND on public transportation, OR any trip that is overnight AND with people who are not in your household. *
I certify that my responses are true and correct. *
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