Sports Team Vaccination Assessment Form
Please complete this form to help ensure team safety and compliance with health guidelines.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Team Name / Role
*
Vaccination Status
*
Fully vaccinated
Partially vaccinated
Not vaccinated
Prefer not to say
If vaccinated, which vaccine(s) have you received?
Pfizer-BioNTech
Moderna
Johnson & Johnson
AstraZeneca
Other
Date(s) of Most Recent Vaccination(s)
Rows
Dose 1 Date
Dose 2 Date
Booster Date
Enter date (MM/DD/YYYY)
Have you experienced any COVID-19 symptoms in the past 14 days?
*
No symptoms
Mild symptoms (e.g., cough, sore throat)
Severe symptoms (e.g., fever, difficulty breathing)
Have you had close contact with anyone diagnosed with COVID-19 in the past 14 days?
*
Yes
No
Not sure
Do you have a medical exemption from vaccination?
Yes (please upload documentation)
No
Upload Medical Exemption Documentation (if applicable)
Upload a File
Drag and drop files here
Choose a file
Cancel
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How comfortable do you feel participating in team activities given your vaccination status?
*
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
Emergency Contact Name and Phone Number
*
Submit Assessment
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