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—Please choose an option—Florham Park Future Boys WhiteFlorham Park Future Boys BlueFlorham Park FireFlorham Park Fire TooFlorham Park HotspursFlorham Park UnitedFlorham Park Blue TideFlorham Park wolFPackFlorham Park PanthersFlorham Park FirestormFlorham Park PhoenixFlorham Park WrathRecreation - PREKRecreation - KINDERRecreation - 1ST GRADERecreation - 2nd/3rd Grade BoysRecreation - 2nd/3rd Grade GirlsRecreation - 4th/5th CoedRecreation - 6th/7th/8th
Cough Within the last 14-days, have you (or immediate family members) experienced a new cough that you cannot attribute to another health condition? YesNo
Shortness Of Breath Within the last 14-days, have you (or immediate family members) experienced new shortness of breath that you cannot attribute to another health condition? YesNo
Soar Throat Within the last 14-days, have you (or immediate family members) experienced a new sore throat that you cannot attribute to another health condition? YesNo
Muscle Aches Within the last 14-days, have you (or immediate family members) experienced new muscle aches that you cannot attribute to another health condition or a specific activity such as physical exercise? YesNo
Fever Within the last 14-days, have you (or immediate family members) had a temperature at or above 100.4° or the sense of having a fever? YesNo
Overall Within the last 14-days, have you experienced any chills, Nausea, Congestion, Runny Nose, Diarrhea, or Headaches ? YesNo
PPE Within the last 14 days, have you (or immediate family members) had close contact, without the use of appropriate PPE, with someone who is currently sick with suspected or confirmed COVID-19?* (Note: Close contact is defined as within 6 feet for more than 10 consecutive minutes) YesNo
Travel Anyone traveling from a known hotspot within the last 14 days will self-quarantine before returning to training or games. Within the last 14 days, have you (or immediate family members) traveled to or returning to NJ from any of the states with increases rates of COVID as outlined in the travel advisory link below.
https://covid19.nj.gov/faqs/nj-information/travel-information/which-states-are-on-the-travel-advisory-list-are-there-travel-restrictions-to-or-from-new-jersey
YesNo
PARENT/GUARDIAN SCREENING ACKNOWLEDGMENT AND CONFIRMATION If the individual answers YES to any of the questions they will not be allowed to participate. This is to certify that I, as parent/guardian with legal responsibility for this participant, do attest to the answers given in this questionnaire to be factual and accurate.
I consent to all the conditions
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