健康チェック� �ートPDF.pdf

Health Check Sheet for Soccer Tournament

Team Name
Representative
Contact Information
Furigana
Date of Birth
Year
Month
Day
Phone Number
Email
Address
Postal Code

Body Temperature from November 27 (Sun) to December 4 (Sun)
Date
Body Temperature upon Waking
Date
Body Temperature upon Waking
Date
Body Temperature upon Waking
Date
Body Temperature upon Waking
11/28 (Mon)
°C
11/29 (Tue)
°C
11/30 (Wed)
°C
12/1 (Thu)
°C
12/2 (Fri)
°C
12/3 (Sat)
°C
12/4 (Sun)
°C

Health Status for the Past 2 Weeks
Check the applicable items

1. No cough, sore throat, or other cold symptoms
2. No fever above normal body temperature
3. No fatigue, shortness of breath
4. No abnormal sense of smell or taste
5. No feeling of heavy body, easy fatigue
6. No close contact with someone who tested positive for COVID-19
7. No family members or close acquaintances suspected of being infected
8. No travel to or close contact with someone from a country/region with government-imposed entry restrictions or observation period within the past 14 days
9. Other concerns (free description)

Parent/Guardian Confirmation (for participants under 18)
Parent/Guardian Name
Phone Number
Email Address
Confirmation Date
Year
Month
Day

This health check sheet is intended to prevent the spread of COVID-19 during soccer tournaments hosted by the Hirosaki Soccer Association. The personal information provided will be strictly managed and used only for the purpose of understanding the health status of team members, determining participation, and necessary communication. The information will not be disclosed to third parties without the individual's consent, except in cases permitted by law or when necessary for public health authorities. The information will be discarded after a period of 2 weeks.