2021 BTSH COVID-19 Attestation Form

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**Please complete this form within 24 hours of your scheduled BTSH game**

Due to the outbreak of COVID-19, BTSH is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance with the guidance of New York state.

Symptoms of COVID-19 include:

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
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, I agree to each statement below and release BTSH from any and all liability for the unintentional exposure or harm due to COVID-19.

Email *

Name *

Team *

Free Agents Only - What team are you subbing for?

Game Date *

Final 4/Championships - October 31 2021

Required

Please complete this form within 24 hours of your scheduled BTSH game *

I have not knowingly been in close contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19; If I have, I can provide a negative test.

I have not tested positive for COVID-19 through a diagnostic test in the past 14 days.

I have not experienced any symptoms of COVID-19 in the past 14 days.

I have not traveled within a state with significant community spread of COVID-19 for longer than 24 hours within the past 14 days.

I understand that BTSH cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.

I affirm that I will wear a mask if I am not fully vaccinated as per the CDC guidance.

Required

A copy of your responses will be emailed to the address you provided.

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