Youth Soccer Player Health Declaration Form
Player Name:
Date of Birth:
Team Name:
Parent/Guardian Name:
Recent Health Status
Has the player experienced any of the following symptoms in the past 14 days?
Fever
Cough
Sore throat
Shortness of breath
Loss of smell or taste
None of the above
Has the player been in contact with anyone diagnosed with a contagious illness in the past 14 days?
Yes
No
Does the player have any chronic medical conditions or allergies?
List any current medications the player is taking:
Any recent injuries or surgeries?
Emergency Contact Information
Emergency Contact Name:
Emergency Contact Phone:
Parent/Guardian Signature
Date