Health Check

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COVID-19 SELF ASSESSMENT

The COVID-19 Self Assessment is required to be completed prior to each practice or game

* Indicates required field

Players Name *

First

Last

Email *

Have you tested positive for COVID-19 in the last 14 days? *

Have you traveled outside Conecticut, Maine, Massachusetts, New Hampshire, Rhode Island or Vermont in the last 14 days? *

Have you been exposed to someone who tested positive for COVID-19 in the last 14 days? *

Do you have any new, unexplained or worsening of the following symptoms? Check all that apply *

Temperature over 100 F Cough Shortness of Breath Diarrhea Nausea of Vomiting Loss of Taste or Smell Sore Throat Fatigue Body Aches Headache Runny Nose or Congestion Chills None of the above

By checking this box, you are stating that all of your answers are true to the best of your knowledge and did not intentionally make any false statements or answers *

YES, all of my answers are true

Todays Date *

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