Imagine Swimming COVID-19 Symptom Survey & Attestation Form

Imagine Swimming COVID-19 Symptom Survey & Attestation Form
Please read carefully as our COVID-19 Attestation and Policies statements have changed.
Parent, Guardian, or Lap Swimmer Name - PLEASE ENTER THE NAME OF THE RESPONSIBLE ADULT ON SITE DURING LESSONS OR LAP SWIM. *

First Name Last Name
Parent/Guardian/Lap Swimmer's Email *
example@example.com
Parent/Guardian/Lap Swimmer's Phone
Please enter a valid phone number.
First Participant's Name (lap swimmers, enter your name here) *

First Name Last Name
Second Participant's Name

First Name Last Name
Third Participant's Name

First Name Last Name
I attest that each of the following are true to the best of my knowledge (CHECK ALL THAT APPLY - LEAVING ANY BLANK WILL INDICATE POSSIBLE EXPOSURE TO COVID-19):

Neither myself nor the participant(s) have experienced any new or unusual symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. I do not believe that either myself or the participant(s) have recently been in close contact, as defined by the CDC, with someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. I am not isolating or quarantining because I or the participant(s) tested positive for COVID-19 or are worried that you may be sick with COVID-19. I myself, and the participant(s), are following all CDC recommended guidelines as much as possible and are limiting our exposure to the Coronavirus/COVID-19. I myself, and all participant(s) 5 years and older have been vaccinated against COVID-19.
Imagine Swimming COVID-19 Attestation
- Neither myself nor the participant(s) have experienced any new or unusual symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
- I do not believe that either myself or the participant(s) have been in close contact with someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
- I am not isolating or quarantining because I or the participant(s) tested positive for COVID-19 or are worried that you may be sick with COVID-19.
- I myself, and the participant(s), are following all CDC recommended guidelines as much as possible and are limiting our exposure to the Coronavirus/COVID-19.
- I myself, and all participant(s) 5 years and older have been vaccinated against COVID-19.
I have read and understood the Imagine Swimming COVID-19 Attestation and attest that all of the statements above are true and apply to each member of my party. *

I agree. I DO NOT agree.
Imagine Swimming COVID-19 Policies & Procedures Agreement
- I agree to have my temperature taken upon entry.
- I agree that I, and each member of my party including children 2 years and older, will wear a proper cloth mask covering the mouth and nose completely. For safety, masks should not be worn inside the pool, but must be worn at all times outside of the pool area.
- I agree that neither I nor any members of my party will eat food while on site.
- I agree to adhere to all COVID-19 protocols, signage, and the direction of staff at all times.
- I agree to remain at least 6’ apart while swimming, except from members of their immediate family.
- I agree to frequently wash or sanitize my hands while in the facility.
I have read and understood the Imagine Swimming COVID-19 Policies & Procedures Agreement above. I agree to comply with all policies & procedures therein, and I agree to follow any additional COVID-19-related directions given by Imagine Swimming staff. *

I agree. I DO NOT agree.
Parent or Guardian Signature *

Clear
Date

Month Day Year
Date
Hour Minutes AM/PM Option
Should be Empty:

Imagine Swimming COVID-19 Symptom Survey & Attestation Form

Please read carefully as our COVID-19 Attestation and Policies statements have changed.