SOAC Football Online Health Self-Assessment Form
In compliance with New York State Department of Health guidelines and the Town of Yorktown, this form must be completed and submitted by every family prior to reporting to any athletic field.
Email *
Player or Coaches Name *
List all people attending game with you (2 Adults Max) *
Today's Date *
MM
/
DD
/
YYYY
Team *
In the last 48 hours have any of the participants listed above had any of the following? *
Required
Did you check any of the above boxes that lists a symptom, AND is the symptom unrelated to a pre-existing condition? *
Required
Has any of the participants listed above been exposed to COVID-19 in the last 24 hours? *
Has any of the participants listed above been tested for COVID-19 in the past 14 days and either tested positive for COVID-19 or are waiting for their test results? *
In the last 14 days, has any of the participants listed above cared for or have close contact with someone diagnosed with COVID-19? *
In the last 14 days, has any of the participants listed above travel out of the state/country to a location designated as high risk by the CDC? ADVISORY: https://coronavirus.health.ny.gov/covid-19-travel-advisory MAP: https://www.cdc.gov/coronavirus2019-ncov/travelers/map-and-travel-notices.html *
If you answered, "YES" to any of the questions above you may NOT attend the scheduled event and should contact your healthcare provider immediately.
Submit
Never submit passwords through Google Forms.
This form was created inside of Shrub Oak Athletic Club. Report Abuse