COVID-19 Questionnaire

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To participate in workouts during the summer recess period, the parent/guardian must complete this form. This form only needs to be completed one time. This is a recommended template for the COVID-19 Questionnaire. Districts can determine the best means (electronic or paper) and platform (Survey Monkey, Microsoft Teams,Google Docs etc.) to administer the questionnaire.

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Student athlete last name *

Student athlete first name *

Parent/Guardian Cell *

Sport *

Girls Basketball

Has your son/daughter been diagnosed with Coronavirus (COVID-19)? *

Yes

If diagnosed with Coronavirus (COVID-19), was your son/daughter symptomatic?

Yes

選択を解除

If diagnosed with Coronavirus (COVID-19), was your son/daughter hospitalized?

Yes

選択を解除

Has any member of the student-athlete’s household been diagnosed withCoronavirus (COVID-19)? *

Yes

Signature of Parent/Guardian *

送信

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このフォームは MCMSNJ 内部で作成されました。