Does your program have an active Covid screening process (ie. Healthcheck)?
Have you, your staff or any of your players had COVID-19 within the last 14 days?
In the last 14 days, have you, your staff or any of your players 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?
Have you, your staff or any of your players 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?
In the last two weeks have you, your staff or any of your players traveled internationally or outside of New Jersey.
In the past 24 hours, have you, your staff or any of your players experienced the following unrelated to seasonal allergies:
Fever Yes No Cough Yes No
Loss of Taste Yes No Loss of Smell Yes No
Aches and Pains Yes No Sneezing Yes No
Sore Throat Yes No Other Covid Symptoms Yes No
Team Representative Name (please print):____________________________________
Signature of Team Representative:______________________________________ Date:
If you answered any of the questions (on behalf of yourself or your team) above in the affirmative, please contact the head coach of the team you are playing immediately to discuss the upcoming event. 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 lacrosse activities and should contact a local healthcare professional.