Daily Self-Screening for Soccer Academy
Please submit this form daily before bringing your child to campus. The form is date stamped upon submittal.
Email *
Child LAST Name *
Child FIRST Name *
Please Select Coach or Event *
Temperature in degrees Fahrenheit taken this morning *
Have you experienced any of the following symptoms in the last 24 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of smell/taste, sore throat, congestion or runny nose, nausea or vomiting, or diarrrhea? *
Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID19? *
Are you fully vaccinated OR have you recovered from a documented COVID19 infection in the last three months? *
Have you been in contact with someone under investigation for, or with a confirmed case of COVID-19 (please see DOH guidelines for exposure) within the last 14 days? *
Are you currently waiting on the results of a COVID19 test? *
Have you traveled out-of-state in the past 10 days? *
Parent Name *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Le Jardin Academy. Report Abuse