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(732) 754-1870

jason@vsa-nj.com

VALENCIA SOCCER ACADEMY

THE FUTURE IS ORANGE

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COVID-19 Screening+Questionnaire

Click here for questionnaire for opponents

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Players + Parents must fill out the form below before any training session + scrimmage + game

COVID-19 Questionnaire:

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It is required for players + parents to fill out this questionnaire before every training, scrimmage or game.

Thank you for your commitment to making VSA a safe environment for our children, parents and coaches

Player Name

Player Last Name

Parent/Gaurdian Email Address:

Within the past 14 days, have you traveled outside of the United States OR visited another state?

Have you or anyone in your household been diagnosed with COVID-19 within the last 14 days?

Have you had ANY of the following symptoms within the past 48 hours?

Fever

Loss of taste or smell

Cough or sore throat

Head or muscle aches

Nasal congestion

Chills

Nausea, diarrhea, or vomiting

Pink eye

No - my children and I do not exhibit any of the above symptoms

Have you been in close proximity to anyone who has tested positive for COVID-19 within the last 14 days?

Please confirm that you have taken your child’s temperature today and his/her temperature is below 100.4°F

Select a date

I accept terms & conditions

Thanks for submitting!

est. 2016 jason@vsa-nj.com 732-754-1870

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