WSC Covid-19 Self-Screening Form
Please fill out this form if you are visiting, playing or practicing at the WSC Shaw Road soccer fields. Thank you!
First and Last Name:
What role are you partaking while at our fields?
WSC team for which you are playing:
Guest team - please answer next question.
If you are a guest at our fields, welcome! What is your home club name?
Have you experienced any of the following symptoms in the past 48 hours: 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?
Have you or any member of your family had a positive Covid-19 test in the last 14 days?
Have you been in close contact with someone who has been diagnosed with or suspected of having Covid-19 in the last 14 days?
Have you traveled to any state on the NYS DOH COVID-19 Travel Advisory list -OR- outside of the country in the past 14 days?
Thank you for playing on the WSC fields. Visitors, fans, and coaches should be wearing face masks. Players should enter the field with face masks until they are instructed to take them off. Thank you for your compliance.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Washingtonville Soccer Club.