Junior-Athletes COVID-19 Checklist
September 12th - October 17th
Date of Clinic *
MM
/
DD
/
YYYY
First Name / Last Name *
Session Attending *
Piccolin 1
Piccolini 2
Ragazzi 1
Giovanotti
Class
In the past 14 days, has your child experienced any symptoms related to Covid-19, including a fever greater than 100.4, new cough, loss of taste or smell, shortness of breath, fatigue, runny nose, or a sore throat *
1 point
In the past 14 days, has your child tested positive for Covid 19 *
1 point
Required
In the past 14 days, has your child been in close contact (within 6 feet and/or longer than 10 minutes) with a confirmed or suspected Covid-19 case? *
1 point
Required
In the past 14 days, has your child traveled outside the country?
1 point
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