New Hartford AYSO COVID 19 Game/Practice Screening
This health screening form is mandatory for any player and accompanying fans/parents prior to playing at New Hartford Soccer Park for Spring 2021 New Hartford AYSO even if the players or fans are not from New Hartford.

Please also have your players check in with coaches to create a list of players participating in games or practice if contact tracing should prove necessary.
Email *
Player Name (first and last) *
Date *
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DD
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YYYY
TEAM - Age group and Name/Number *
CONTACT - Phone number *
CONTACT - Email Address *
Names of parents or fans also in attendance *
COVID 19 SYMPTOMS INCLUDE THE FOLLOWING: Fever, chills, cough, shortness of breath or difficulty breathing, muscle or body aches, fatigue, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting or diarrhea
Have you or any member of your party/family been diagnosed with COVID 19 in the last 14 days? *
Have you or any member of your party/family had any of the above symptoms of COVID 19 in the past 14 days? *
Have you or any member of your party/family been in close contact with a confirmed or suspected case of COVID 19 in the past 14 days? *
IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE REFRAIN FROM HAVING YOUR CHILD PLAY OR PARTICIPATE IN SOCCER TODAY. PLEASE CONTACT A PHYSICIAN OR THE DEPARTMENT OF HEALTH IMMEDIATELY FOR FURTHER GUIDANCE.
THANK YOU ON BEHALF OF NEW HARTFORD AYSO, NHAYSO2020@GMAIL.COM
NEW HARTFORD AYSO
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