COVID-19 Acknowledgement Form
Please complete this form prior to each clinic session.  Thank you
登入 Google 即可儲存進度。瞭解詳情
電子郵件 *
Player Last Name *
Player First Name *
Date *
MM
/
DD
/
YYYY
My child will be:
If your child will be arriving late to camp or leaving early from camp please indicate the time so that we may have a staff member available to meet or bring your child to the pick-up area.
時間
:
Within the last 14 days has your child been diagnosed with COVID-19 or had a test confirming they had the virus? *
Does your child  live in the same household, or have they had close contact (been within 6 feet for over 10 minutes) with someone who has been in isolation for COVID-19 or has had a test confirming they have the virus, in the past 14 days? *
Has your child had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by another reason?  (Fever of at least 100.4 or chills, Cough, Shortness of breath or difficulty breathing, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) *
By submitting this form and including your name you are acknowledging that all of the information is true and correct.   Please add the name of the person filling out this form.   *
系統會透過電子郵件將你的作答內容複本傳送到你所提供的地址。
提交
清除表單
請勿利用 Google 表單送出密碼。
reCAPTCHA
隱私權條款
Google 並未認可或建立這項內容。 檢舉濫用情形 - 服務條款 - 隱私權政策
Google 表單