COVID-19 Questionnaire | Union Catholic Regional High School

Student Name: *

Email Address: *

Date: *

Month

Day

Year

Parent/Guardian Name: *

Parent/Guardian Cell: *

Has your son/daughter been diagnosed with Coronavirus (COVID-19)?: *

Yes

No

If diagnosed with Coronavirus (COVID-19), was your son/daughter symptomatic?:

Yes

No

If your son/daughter was symptomatic, when was the last date (mm/dd/yyyy) of their symptoms?:

If diagnosed with Coronavirus (COVID-19), was your son/daughter hospitalized?:

Yes

No

Has any member of the student-athlete’s household been diagnosed with Coronavirus (COVID-19)?: *

Yes

No

If a member of the student-athlete's household was diagnosed, when was the last date (mm/dd/yyyy) of their symptoms?:

If you have traveled out of state within the last two weeks, please list the states that you have visited.:

When did you return from the state? Provide an exact date.:

Have you played on any club, travel, or other organized sports teams within the last 14 days?: *

Yes

No

If yes to any of the above, when was the last time you participated? Provide an exact date.: