REGAL 2021 SECOND GRADE BASKETBALL Health Screening
All athletes and Volunteers must complete this form prior to every practice or game. The parent will fill out the top part of this form, and then once the volunteer has taken the individual's temperature, the parent will enter the temperature and submit the form.

IF YOU ANSWER YES TO ANY OF THE HEALTH QUESTIONS, PLEASE GO HOME AND DO NOT ATTEND YOUR PRACTICE!!
Email address *
Participant/Volunteer Name (Last, First) *
Location *
What time does the practice/game start? *
Is participant/volunteer a Minor or an Adult *
IF YOUR ANSWER TO ANY OF THESE QUESTIONS IS YES, PLEASE GO HOME AND DO NOT ATTEND PRACTICE OR GAME
Did you/participant take fever reducing medication today? *
Does participant/volunteer have any of the following symptoms? Please answer NO or YES for all *
NO
YES
Fever/chills
Cough
Shortness/Difficulty Breathing
Fatigue
Muscle/body aches
Headaches
Loss of taste/smell,
Sore Throat
Congestion
Runny Nose
Nausea/Vomiting
Diarrhea
Do any members of the participant/volunteer's household have any of the above symptoms? *
Has the participant/volunteer had close contact with anyone diagnosed with COVID-19 in the past 14 days? *
Is participant isolating or quarantining because they 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 COVID19 test? *
Have you traveled outside of the tri-state area? (Tri-State area includes NY, PA, CT & DE)
Clear selection
IF YOUR ANSWER TO ANY OF THESE QUESTIONS IS YES, PLEASE GO HOME AND DO NOT ATTEND PRACTICE OR GAME
Please enter the full name of the volunteer taking the participant/volunteer's temperature *
Please enter the temperature on the thermometer once the volunteer scans the participant/volunteer: *
Submit
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