Staffordshire Surge COVID-19 Screening Form - 16/05/2021
The health and safety of our coaches, players and staff is important to us. Due to the ongoing and rapidly changing situation with Covid-19, in order to protect your health and that of your family, friends and colleagues, we require you to complete this form prior to American Football activity taking place.
Name: *
Contact Number: *
Position: *
Do you currently have any symptoms of COVID-19 including, but not limited to, a high temperature, a new continuous cough, or a loss or change to your sense of taste or smell? *
Have you been in contact with someone who is suspected to, or known to have tested positive for COVID-19 in the last 14 days? *
Have you been in contact with anyone with one or more of the symptoms noted previously (temperature, a new continuous cough, or a loss or change to sense of taste or smell) in the past 14 days but who has not yet had a test/tested positive? *
In the last 14 days, have you travelled internationally to a destination NOT on the list of countries exempt from quarantine requirements as detailed by the UK Government? *
By ticking the 'Agree' box below and submitting this form, you are acknowledging that the Staffordshire Surge will be putting in place safety measures to help protect everyone's safety and that you will adhere to these measures, as and when you are so advised. *
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