Student Information For Covid 19 Testing

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This form must be filled out prior to testing. Please fill out this entire form. When you are done, make sure you type in your name and date for your digital signature. MAKE SURE YOU BRING YOUR STUDENT ID THE DAY OF THE TESTING

Email *

First Name *

Middle Name

Last Name *

Street Address *

Unit #

City *

State *

Zip Code

Phone *

Email *

Date Of Birth *

YYYY

Birth Gender *

Female

Male

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Other

Race *

White

Asian

Native Hawaiian / Pacific Islander

Alaskan Native

Black / African-American

Unknown

Are you currently experiencing Any of the following symptoms (check all that apply) *

Yes

Fever or Chills

Cough

Muscle or Body Aches

Sore Throat

Diarrhea

Shortness of breath or difficulty breathing

Headache

Runny Nose

Required

Consent for Testing: I understand that Governor Herbert signed Executive Order 2020-73 on 8 November 2020. It requires each participant including each coach, trainer, staff member, and athlete, to wear a face mask, except while actively performing as an athlete AND to submit to and receive a negative test result from a diagnostic test to determine current COVID-19. The results of the test will be released to the Southwest Utah Public Health Department. My parent(s) and/or legal guardian(s), are aware of and consent to this requirement. If I refuse to comply with this requirement or if I tamper with the test or try to cheat the testing results, I understand that I will not be allowed to participate in the activity. TYPE YOUR NAME BELOW AS YOUR DIGITAL SIGNATURE *

Assigned testing date (for this week) *

YYYY

Send me a copy of my responses.

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