NCV Daily COVID-19 Questionnaire
Please complete this form on the day of your tryout with Nickel City Volleyball.
This form must be submitted BEFORE participating in your session.
Email address *
Today's Date *
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Participant Full Name *
Parent/Guardian Full Name *
Parent/Guardian Phone Number *
COVID-19 SCREENING
Answer the questions in this section as it relates to the participant and their household/immediate family members.
Participant and household members DO NOT currently have, nor have experienced, COVID-19 related symptoms within the last 14 days. *
Symptoms of COVID-19 include, but are not limited to: Fever, Fatigue, Dry Cough, Difficulty Breathing/Shortness of Breath, New Loss of Taste and/or Smell, Gastrointestinal upset (including vomiting and diarrhea)
Participant and household members HAVE NOT been diagnosed with COVID-19 within the past 30 days. *
Participant and household members HAVE NOT knowingly been exposed to anyone diagnosed with COVID-19 within the past 14 days. *
Participant and household members HAVE NOT traveled outside of the country or to any state considered to be a “hot spot” for COVID-19 infections within the past 14 days. *
Note the Restricted travel states that require 14 days of quarantine upon return: https://coronavirus.health.ny.gov/covid-19-travel-advisory
Nickel City Volleyball Club has put in place preventative measures to reduce the spread of COVID-19. I acknowledge that Participant must comply with all set procedures to reduce the spread while participating in club related activities. *
I understand that the risk of becoming exposed to and/or infected by COVID-19 may result from the actions, omissions, or negligence of participants, staff and their families. I understand that Nickel City Volleyball Club cannot be held liable for any exposure to COVID-19 caused by misinformation collected or the actions, omissions or negligence of participants, staff and their families. *
By providing the electronic signature below, I attest that all information provided on this form is accurate.
Electronic Signature *
Parent/Guardian required if Participant is under 18
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