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Player Covid Health Questionnaire

Participant’s Name:     ____________________________

Team Name:                ____________________________

Day of Event:              ____________________________

 

  1. Have you/participant had COVID-19 within the last 14 days?

Yes  No

  1. In the last 14 days, have you/participant been in close contact with anyone you know: (a) who exhibited the symptoms of COVID-19, (b) who is/was being tested for COVID-19, (c) who has COVID-19, or (d) who was exposed to someone with COVID-19?

Yes  No

  1. In the last twenty-four (24) hours, have you/participant had any signs or symptoms of a fever such as chills, sweats, felt “feverish”, aches/pains, or had a temperature that is elevated for you or 100.4F or greater?

Yes  No

 

  1. In the last twenty-four (24) hours, have you/participant experienced fatigue, coughs, sneezing (other than seasonal allergies), sore throat, diarrhea, loss of smell, loss of taste or nausea/vomiting?

Yes  No

 

  1. Over the last two weeks, has the participant or their immediate family travelled/visited any of the states that are currently on the quarantine list for the State of New Jersey?

Yes  No

In consideration of being allowed to participate in the WLC program(s), related events and activities, I, the undersigned, acknowledge, appreciate, and agree that there are risks to my participant/me of exposure to, directly or indirectly, arising out of, contributed to, by, or resulting from an outbreak of any and all communicable disease, including but not limited to, the virus “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)”, which is responsible for Coronavirus Disease (COVID-19) and/or any mutation or variation thereof.   

I, for myself and on behalf of the participant, and our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Westfield Lacrosse Club aka WLC, its officers, officials, agents and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any ILLNESS (including but not limited to SARS-CoV-2 and COVID-19), INJURY, DISABILITY OR DEATH I, or the participant, may suffer, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. 

I, on behalf of the participant and myself individually, HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I, on behalf of the participant and myself individually, HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. 

This is to certify that I, as parent/guardian with legal responsibility for the participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incidents to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.

If the participant has exhibited any of the above symptoms or you answered YES to any of the above questions, the participant should not attend the event/practice/game.  If the participant has been diagnosed with Covid-19, the participant should not return to participating in future WLC events until cleared by their physician. 

 

Participants Name (please print):

Signature of Responsible Adult: _________________________________ Date: