COVID-19 Health Screening Form (Youth Athletics)
Date
Participant's Name
Parent/Guardian Name
Team/Organization
Contact Number
Health Screening Questions
1. Has the participant experienced any of the following symptoms in the past 24 hours? (Fever, cough, shortness of breath, sore throat, loss of taste or smell, nausea/vomiting, diarrhea, chills, muscle aches, headache)
Yes
No
2. Has the participant been in close contact with anyone who has tested positive for COVID-19 or is awaiting test results?
Yes
No
3. Has the participant tested positive for COVID-19 in the past 10 days?
Yes
No
4. Has the participant traveled internationally or out of state in the last 14 days?
Yes
No
Parent/Guardian Signature
Signature
Date