COVID-19 Exposure Report Form
AYSO Region 88 Glendale / La Crescenta / Montrose
If you as a Volunteer for Region 88, or your child as a player or volunteer for Region 88, 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 L.A. County guidelines. The form will help us keep track of players and volunteers who are not available to participate due to self-isolation.
This report is for a:
Player
Volunteer (Youth)
Volunteer (Adult)
Contact Information
Parent/Guardian Name
*
First Name
Last Name
Player or Youth Volunteer Name
*
First Name
Last Name
Player's Division (Age Group)
U4 / 5U
6U
7U
8U
10U
12U
14U
16U
19U
VIP
Volunteer (Adult) Name
*
First Name
Last Name
Primary Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Exposure / Symptoms
Please provide information regarding the player's or volunteer's symptoms currently being experienced.
Where did the exposure happen
*
AYSO Practice
AYSO Game
School / University
Job location
Home (e.g. a family member)
Other
Does the person exposed have any of the symptoms noted below
*
Yes
No
Please indicate the symptoms the affected person are currently having:
Cough
Shortness of breath
Fever
Loss of taste or smell
Sore throat
Fatigue
Muscel or body aches
Nausea or vomiting
Diarrhea
Congestion or runny nose
No symptoms at this time
Other
Has the affected person been fully or partially vaccinated against COVID-19?
Fully vaccinated with 2-doses for Moderna or Pfizer or 1 shot for J&J
Partially vaccinated with 1 dose of Moderna or Pfizer
No
Other
Has someone from the team been notified of this COVID-19 diagnosis (including if the affected person is the players' parent)?
Head Coach
Assistant Coach
Team Parent
Not notified
Other
Additional Comments/Information
Submit
Should be Empty: