Massachusetts Youth Soccer
Return to Soccer Activity Review and Compliance Waiver
Adult Member
The undersigned, hereby represents, warrants and acknowledges that I have read and
understood my responsibilities as a Coach/Volunteer according to the Massachusetts
Youth Soccer COVID 19 Soccer Protocols prior to participating in any town program,
club, or league soccer related activities. This includes, but is not limited to, individual or
team practices, clinics, training, games, tournaments, meetings or classes.
I attest that the information I am providing below is true and accurate. Prior to
participating in any soccer related activities I will ensure that I have not experienced any
of the following symptoms within the last 48 hours: (please place an X in each box to
indicate you have read.)
Fever (over 100.4 degrees fahrenheit) Temperature will be taken before every
Shortness of breath, or difficulty breathing
Muscle aches
Sore throat
Loss of smell or taste, or a change in taste
Nausea, vomiting or diarrhea
Place an X in each box below indicating you have read and acknowledged each of the
following statements as being true and correct:
The player has not been in close contact with anyone who has exhibited
symptoms of COVID-19 in the last 10 days.
The player has not had contact with anyone who has had a confirmed case of
COVID-19 in the last 10 days.
The player is not restricted from participating by a healthcare provider.
The player has not traveled in the past 10 days or is not subject to quarantine by
the Commonwealth of Massachusetts travel advisory. If so, all of the necessary
steps required by the advisory will be completed by the player prior to returning
to soccer related activities.
The player has not recently traveled to a restricted area that is under a level 2, 3
or 4 travel advisory according to the U.S. State Department.
Face Mask Exemption:
Applies only to individuals with a documented medical condition or disability that
makes them unable to wear a face covering. A facial covering means a face
mask or cloth facial covering that completely covers the nose and mouth.
Participants for all sports must wear facial coverings on the bench or sidelines at
all times and in any huddles or time-outs from active play.
I am able to provide documentation for the medical condition or disability
that applies to the exemption as stated above.
If at any time you are unable to confirm the above criteria you must be restricted from
participation and should contact your healthcare provider.
I understand that any falsification or omission of the information I provided above, could
result in a disqualification from participation in an Massachusetts Youth Soccer
Association sanctioned soccer related activity for no less than a year.
Name ____________________________________
Member Organization__________________________________
Signature _________________________________________________
Print Name of
Email address___________________________________________
By electronically signing a signature or its equivalent to this electronic document, the above signee fully
understands they are consenting to the terms included within the Return to Soccer Activity Review and Compliance
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