Health Screen Survey | 17U 2004 Girls
Please complete the questions below the morning of the your event. No candidate will be able to participate without having completed the Symptom Pre-Screen. All questions will be recorded/kept confidential. If an answer to any question is "yes", please stay home.
Participant Name *
Are you attending practice? *
Tryout Shirt Color *
Tryout Shirt Number *
Is anyone in the household (player, parents, siblings, etc) feeling sick? (symptoms could include Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea, etc.) *
Has anyone in your family been exposed to a COVID-19 positive individual or a suspected COVID-19 positive individual in the last 14 days? *
Have you traveled in the last 14 days to an area with travel restrictions, as identified by the PA Department of Health or the Centers for Disease Control and Prevention? (Alabama, Arizona, Arkansas, California, Florida, Georgia, Idaho, Kansas, Louisiana, Mississippi, Missouri, Nevada, North Dakota, Oklahoma, South Carolina, Tennessee, Texas) *
Person Filling Out Form *
Relation to Participant *
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