Pre-practice & event Health Screening
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First Name *
Last Name *
Phone (optional)
Email (optional)
What Lacrosse Organization are you affiliated with? *
What is your Team / Affiliation *
Event / Practice Location *
Does your player have any of the following symptoms that are not caused by another condition in the past day (24 hours)?                                                                                                                                                                                  -- Fever (100.4F) or chills                                                           -- Cough                                                                                                 -- Shortness of breath or difficulty breathing                                -- Unusual fatigue                                                                                  -- Muscle or body aches                                                                           -- Headache                                                                                            -- Recent loss of taste or smell                                                                   -- Sore throat                                                                                               -- Congestion or runny nose                                                                     -- Nausea or vomiting                                                                           -- Diarrhea *
Yes
No
please check yes or no
Has your player been in close contact (within 6ft for 15 minutes or longer) with anyone with confirmed COVID-19? *
Yes
No
please check yes or no
Have you had a positive COVID-19 test for active virus in the past 10 days, or are you awaiting results of a COVID-19 test? *
Yes
No
please check yes or no
Within the past 14 days, has a public health or medical professional told your student to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19? *
Yes
No
please check yes or no
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