Cherry Hill Soccer Club Daily Health Questionnaire
To keep you and all of our players, participants, coaches and their families safe, we are following
the guidelines and recommendations of the New Jersey Department of Health and requiring that
every participant be assessed for COVID-19 symptoms and risk factors each day before engaging in
any youth soccer-related activity (practices, competitions, events and/or before entering into any
facilities, etc.). The below questionnaire must be completed for each player for each youth soccer
activity on the day of the subject activity before the player will be permitted to engage in the
subject activity.
*If you answer yes to any of the following questions please stay home.
Player Last Name *
Player First Name *
CHSC event *
Was your temperature above 100.3 F today? *
1 point
Within the last 14 days, have you been exposed to, or come into contact with, anyone you know: (a) who has COVID-19, (b) who had symptoms consistent with COVID-19, or (c) who was exposed to someone with COVID-19? *
1 point
Have you or a family member visited a high risk country or state or have extended close contact with someone who has within the last 14 days? *
1 point
Have you had any signs or symptoms of a fever in the past 24 hours such as chills, sweats,felt "feverish," or had a temperature that is elevated for you or 100.4F or greater? *
1 point
Do you have any of the following symptoms? - Fever or chills• Cough• Shortness of breath or difficulty breathing• Fatigue• Atypical muscle pain or body aches• Headache• New loss of taste or smell• Sore Throat• Congestion or runny nose• Nausea or vomiting• Diarrhea *
1 point
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