NAME _______________________ DATE_____________________

To keep you and all of our players, participants, coaches and their families safe, we are following the guidelines and recommendations of the CDC and requiring that every participant be assessed for COVID-19 symptoms and risk factors each day before engaging in any youth soccer-related activity (practices, competitions, events and/or before entering into any facilities, etc.).

The below questionnaire must be completed for each player for each youth soccer activity on the day of the subject activity before the player will be permitted to engage in the subject activity.

1. Was your temperature above 100.4F today ? (Yes/No)

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2. Have you had COVID-19 within the last 14 days, or have you been tested (positive) for it within the last 14 days? (Yes/No)

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3. Have you had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt “feverish,” or had a temperature that is elevated for you or 100.4F or greater? (Yes/No)

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4. Do you have any of the following that are new symptoms? (Yes/No)

• Fever or chills,Cough, Shortness of breath or difficulty breathing, Fatigue, Atypical muscle pain or body aches, Headache, New loss of taste or smell, Sore Throat, Congestion or runny nose, Nausea or vomiting, Diarrhea

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5. Have you traveled internationally or outside of the state in the last 14 days? (Yes/No)

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6. Within the last 14 days, have you been exposed to, or come into contact with, anyone you know: (a) who has COVID-19, (b) who is/was being tested for COVID-19, (c) who had symptoms consistent with COVID-19, or (d) who was exposed to someone with COVID19? (Yes/No)

Regardless of how you answer the questions provided in this survey, if you have symptoms consistent with COVID-19 or feel you may be developing symptoms consistent with COVID-19, you cannot attend or participate in any youth soccer activities and should contact a local healthcare professional.