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2. COVID-19 Daily Pre-Screening Questions
4. To participate in Recreation activities, each student must complete this form daily before their scheduled tryout, practice or game. Screening questionnaires must be completed and submitted prior to arriving at any Recreation activity. * Required
6. Email Address*
10. STUDENT ATHLETE INFORMATION
12. Athlete First Name*
13. Athlete Last Name*
15. Parent/Guardian Cell Phone Number*
17. Sport/Activity*
    -- Select One --WrestlingK-6 Diff-Abilities ProgramAdult Diff-Abilities ProgramSoftball - 10USoftball - 12USoftball - 14U2nd-4th Grade Boys Lacrosse5th/6th Grade Boys Lacrosse7th Grade Boys Lacrosse8th Grade Boys Lacrosse2nd-4th Grade Girls Lacrosse5/6th Grade Girls LacrosseK-2 Boys Lacrosse ClinicK-2 Girls Lacrosse ClinicVolleyball ClinicK-2 Tennis3rd-8th Intermediate Tennis3rd-5th Grade Tennis6th-8th Grade TennisAdult Tennis3/4th Grade Pick Up Basketball5/6th Grade Pick Up Basketball7/8th Grade Pick Up Basketball 1-2 Grade Softball3-4 Grade Intown Softball5-6 Grade Intown Softball7-8 Grade Intown SoftballSpring Break Multisport Camp
21. SYMPTOMS SCREENING
23. Are you experiencing any of the following symptoms?
25. Temperature of 100.4°F or higher*

    1. Yes
    2. No
26. Cough or shortness of breath*

    1. Yes
    2. No
28. Sore throat*

    1. Yes
    2. No
29. Chills*

    1. Yes
    2. No
31. Muscle aches or rigors*

    1. Yes
    2. No
32. Headache*

    1. Yes
    2. No
34. New loss of taste or smell*

    1. Yes
    2. No
35. Abdominal pain, nausea, vomiting, or diarrhea*

    1. Yes
    2. No
39. RECENT HISTORY REVIEW:
41. Please respond to each of the following questions.
43. Have you had close contact with someone who is currently sick?*

    1. Yes
    2. No
45. Have you been diagnosed with COVID-19 in the past three weeks or have reason to believe you have COVID-19?*

    1. Yes
    2. No
47. Have you traveled or had close contact with anyone who has traveled internationally in the last 14 days?*

    1. Yes
    2. No
51. If you took your temperature this morning, what was the reading?
55. TRAVEL ADVISORY QUARANTINE (**LIST FREQUENTLY UPDATED**) Please note that the Governor's Office has issued a 14-Day Travel Advisory Quarantine that applies to anyone arriving in New Jersey from any of the states identified on the list found at the website linked below:
57. Which states are on the travel advisory list? Are there travel restrictions to or from New Jersey?
    State Restricted List
59. **THESE STATES ARE SUBJECT TO CHANGE. PLEASE REVIEW THE LIST CAREFULLY EACH TIME YOU RESPOND TO THIS QUESTION**
63. Have you traveled back to New Jersey from any of the states listed above within the past 14 days? **

    1. Yes
    2. No
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65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

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