COVID-19 Exposure Status for AYSO Region 13
This form is to alert us that you have been exposed to a COVID-19 Case
If you as a Volunteer for Region 13, or your child as a player or volunteer for Region 13, have been exposed to a person who tested positive for COVID-19, please fill out this form and self-isolate as per guidelines.
For example, if a player has been notified by the school that there was a close contact or an exposure to a COVID case and that the player must self-isolate (quarantine), then please complete this form and honor the self-isolation as per LA County guidelines. The form will help us keep track of players and volunteers who are not available to participate due to self-isolation. Thank you.
Full Name of person who had the exposure
Where did the exposure(s) happen?
Home (e.g. a family member)
Name of School
Has the exposed person received quarantine instructions from organization where exposure occurred or from a Public Health Department?
The person who was exposed is a
Full name of Child's parent
Email Address for Parent or Adult Volunteer
Best phone number for Parent or Adult Volunteer (cell preferred)
Please enter a valid phone number.
Division(s) where the exposed person plays or volunteers
Name of coach of the team
indicate if you don't know
Date of exposure
Please provide information regarding the exposed person's symptoms currently being experienced.
Does the exposed person have any of the symptoms listed further below?
When did symptoms start?
Please indicate the symptoms the exposed person is currently having:
Shortness of breath
Loss of taste or smell
Muscle or body aches
Nausea or vomiting
Congestion or runny nose
No symptoms at this time
Has the exposed person been fully or partially vaccinated against COVID-19?
Fully vaccinated AND booster dose
Fully vaccinated with 2-doses for Moderna or Pfizer or 1 shot for J&J.
Partially vaccinated with 1 dose of Moderna or Pfizer.
Have the player's/volunteer's coach and team manager been notified of this COVID-19 exposure?
Coach and Manager
Any explanatory remarks:
Should be Empty: