COVID-19 Symptom Checklist for Dixie SC Members
All participants (team officials, players, and club staff) must complete and submit form below a maximum of 1-hour prior to each training session. Fill out the form with honesty. If an individual answers "YES" to any of the below questions, they are not permitted to participate in any in-person soccer activity for a minimum of 14 days. Please notify your team coach/manager and Club (Angela Malvaso at dixiescsecretary@hotmail.com), if you have responded "YES" to any of the questions below.
Participant Name
*
First and Last name
Team Name
*
Board Member
Club Staff
G2011 Black (Paul)
G2010 REP (Chali)
G2009 Black (Craig)
G2009 Blue (Sal)
G2009 White (Alex)
G2008 Black (Rocco)
G2008 White (Paul)
G2007 Black (Dino)
G2007 Blue (Marc)
G2007 White (Paul)
G2006 Black (Geoff)
G2005 Black (Wayne)
G2005 White (Dan)
G2004 Black (Chali)
G2004 Blue (Dino)
G2004 White (Paul)
B2012 REP (Andrew)
B2011 REP (Omero)
B2010 REP (Craig)
B2010 Navy (Brandon)
B2009 Black (Daniel)
B2009 Blue (Sean)
B2008 Black (Dong)
B2008 Blue (Tony)
B2007 Black (Shawn)
B2007 Blue (Igor)
B2006 Black (Rover)
B2006 Blue (Jonathan)
B2005 Black (Rich)
B2005 Blue (Anthony)
B2004 Black (Leo)
B2003 Black (John)
Please choose correct option
Emergency Contact Name
*
First and Last name
Phone Number
*
-
Area Code
Phone Number
E-mail Address
*
example@example.com
RTP COVID-19 SYMPTOM CHECKLIST
Does the participant (team official/player/member) have any of the below symptoms?
*
YES
NO
Fever (greater than 38.0c)?
1
2
Cough?
3
4
Shortness of breath/difficulty breathing?
5
6
Sore throat?
7
8
Runny nose?
9
10
Has anyone in your household experienced any of the above symptoms in the last 14 days?
11
12
Have you, or anyone in your household traveled outside of Canada in the last 14 days?
13
14
Have you, or anyone in your household been in contact in the last 14 days with someone who is being investigated as a suspected case of COVID-19?
15
16
Are you currently being investigated as a suspected case of COVID-19?
17
18
Have you tested positive for COVID-19 within the last 10 days?
19
20
Signature
Submit
Should be Empty: