Coronavirus Self Declaration Form

Coronavirus Self Declaration Form

For the health and safety of our community, declaration of illness is required each day before a meeting. Be sure that the information you'll give is accurate and complete. We understand that you may be anxious to get back, but please make sure it is not at someone else's expense. Answer these questions honestly. Please seek immediate medical attention if you have any of the COVID-19 signs.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Weight
Have you ever been diagnosed with COVID-19?*

YesNo
Have you been in contact with people being infected, suspected or diagnosed with COVID-19 within the last 14 days?*

YesNo
Have you been in one of the states on travel advisory within the last 14 days?*

YesNo

Please state whether you've experienced/are experiencing the following*

Please note, Since the signs and symptoms of COVID-19 can be fairly non-specific and not just respiratory symptoms, it is recommended that athletes should not be in close sustained contact with anyone who is sick for 14 days prior to our meetings. This will reduce the risk of introducing COVID-19 into your meeting group by someone who may have COVID-19 but isn't experiencing any symptoms yet.
I acknowledge that the information I've given is accurate and complete.
Date*

MonthDayYear
Date
Signature

Clear
Should be Empty: