Player Health Screening Form

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Parents must complete prior to player participating in events.

Email *

Player Name *

Manager Name - Team (Listed Alphabetically by Manager Last Name - Division by Age) *

Player Temperature? * NOTE CHILDREN WITH TEMPARATURE of 100.4° OR ABOVE SHOULD BE KEPT HOME. *

Has your child experienced any of the following symptoms within the past 24 hours? If TWO OR MORE of the following symptoms are checked off please keep your child home and notify the team manager for further instructions. PLEASE NOTE THAT ANY CHILD EXPERIENCING VOMITING OR DIARRHEA SHOULD STAY HOME UNTIL FREE OF SYMPTOMS FOR 24 HOURS. *

Chills

Muscle Ache or Pain

Headache

Sore Throat

Fatigue

Congestion Runny Nose

NONE OF THE ABOVE SYMPTOMS ARE PRESENT IN MY CHILD

Required

If ANY of the following symptoms are checked off, please keep your child home and notify team manager and wait for further instructions. *

Loss of Taste or Smell

Persistent Cough

Shortness of Breath / Difficulty Breathing

NONE OF THE ABOVE SYMPTOMS ARE PRESENT IN MY CHILD

Required

Has your child had close contact (within 6 feet for at least 15 minutes in a 24 hour period) with an individual with COVID-19, or has anyone in your household been diagnosed with COVID-19* If YES is checked off, keep your child home and refer to NJ State Health Dept. / CDC Guidelines for quarantine instructions. *

Yes

A copy of your responses will be emailed to the address you provided.

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