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Student First Name:
*
Student Last Name:
*
Sport:
*
- Select -
Boys Soccer
Cheerleading
Cross Country
Field Hockey
Football
Girls Soccer
Girls Tennis
Date of Birth:
*
/
/
Cell Phone:
*
Email:
*
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 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
Does your son/daughter have any pre-existing medical conditions and/or YES NO are they immunocompromised (e.g. diabetes, asthma, auto-immune Disorders, etc.):
*
Yes
No
***If the answer is yes, you must have a note from a physician before your child will be permitted to participate in any voluntary workouts
Has your son/daughter traveled within the past 14 day to any States on the NJ Quarantine list?:
*
Yes
No
Send me a copy of the completed form to this email address:
