Summer Skills Sessions Waiver
COVID-19 Screening Questionnaire Form
Pentucket Youth Lacrosse would like to help ensure the Health and Safety of all our players, and coaches during the COVID- 19 pandemic. Out of an abundance of caution, we would like our parents to check the temperature of the parent and player attending our exercise and skill sessions and complete an updated form for every session you attend.

In accordance with CDC guidance, any potential attendee with a temperature at or above 100.4-degrees Fahrenheit must not come to the session and should consider contacting their health care provider.

As an additional early warning process, Pentucket Youth Lacrosse is asking all session attendees to complete the below questionnaire. This is to help you and us identify high-risk individuals who may not be displaying symptoms yet. If you or your daughter could be perceived as high risk, (and answers "yes" to any of the questions below) please do not attend a session or sessions.

Thank you for your patience and understanding.

For the purposes of this questionnaire, direct contact means:
a) Greater than 15 minutes of face-to-face contact in any setting with a presumptive or confirmed case in the period extending from 24 hours before the onset of symptoms in the confirmed case
b) Sharing of a closed space with a presumptive or confirmed case for a prolonged period (e.g. more than 2 hours) in the period extending from 24 hours before the onset of symptoms in the confirmed case.

If you answer YES to ANY of the questions below, do NOT attend the exercise and skills sessions. Contact Angela Palmer, President of PYL (angela@plantsnouveau.com) with any questions.

If you feel you may be at a higher risk from contracting COVID-19, Pentucket Youth Lacrosse encourages you to practice prudent social distancing and consider whether your presence at exercise and skills sessions is dangerous for you and/or the other attendees.
Email address *
Name of Parental Guardian *
Player # 1 Name *
Player #2 Name
Player # 3 Name
Contact (Cell Phone for Players Guardian) *
Age Group ( for last school year) *
I will be attending practice on 6/29 *
1. Has your child or anyone in your household flown or traveled out of the country in the past 14 days? *
2. Has your child or anyone in your household been in direct contact with someone that traveled internationally in the past 14 days? *
3. Has your child or anyone in your household experienced dry cough, difficulty breathing, sore throat, and fever in the past 14 days? *
4. Has your child or anyone in your household been in direct contact with someone exhibiting any of the above-mentioned symptoms? *
5. Has your child or anyone in your household been in direct contact with someone who has been directed to self-isolate or has been diagnosed with having contracted COVID-19 in the past 14 days? *
6. Please indicate that you understand this request and that information is current and truthful. *
I affirm that entering my name below and submitting this form constitutes an electronic signature of this form. *
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