JBC COVID-19 Self Declaration Form
For the health and safety of our community, declaration of illness or contact tracing is required by JBC. Be sure that the information you'll give is accurate and complete. Please seek medical attention if you have any of the COVID-19 symptoms.
Impacted Person's Name
*
First Name
Last Name
Parent 1 Name
*
First Name
Last Name
Parent 2 Name
First Name
Last Name
Parent Phone Number
*
Please enter a valid phone number.
Parent Email
*
example@example.com
Coach's Name
*
First Name
Last Name
Team (ie. 5th Boys Gold)
*
Have you been confirmed or diagnosed with COVID-19?
*
Yes
No
Have you been been in close contact with a person that is confirmed or diagnosed with COVID-19?
*
Yes
No
Date of diagnosis or contact
*
-
Month
-
Day
Year
Date
Have you experienced any of the symptoms noted below
*
Yes
No
Fever (higher than 100.4)
Cough
Shortness of Breath
Persistent Pain in the Chest
New Loss of Taste or Smell
Muscle Aches
Fatigue
Sore Throat
Nausea/Vomiting/Diarrhea
Headache
Date that symptoms first started/appeared (if applicable)
-
Month
-
Day
Year
Date
Since symptoms first appeared and/or contact was made, have you attended any other JBC functions? Please include function (game, practice, etc.) and dates.
*
I acknowledge that the information I've given is accurate and complete.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Clear
Submit
Should be Empty: