Racer X Aquatics COVID-19 Screening

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First Name *

Last Name *

In the last 14 days, have you had a positive COVID-19 test? *

Yes

In the last 14 days, have you been in close contact with anyone who has tested positive? *

Yes

In the last 72 hours have you had close contact with someone diagnosed with COVID‐19? *

Yes

In the last 72 hours have you had close contact with who is under investigation or in quarantine for possible COVID‐19 infection? Close contact is defined as any individual who was within 6 feet of an infected person for at least 15 minutes. *

Yes

In the last three days have you had any of the following symptoms: *

Fever greater than 100.4° F

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

Diarrhea

Vomiting

I have not and do not have any of the above symptoms

In the last 24 hours, have you taken fever-reducing or other symptom-altering medicines due to COVID or COVID like symptoms (e.g. ibuprofen, Tylenol, or cough suppressants)? *

Yes

Do you currently have COVID-19, or are you caring for someone who has COVID-19? *

Yes

By checking below I certify that the responses provided above are true and accurate to the best of my knowledge and participation in this event is voluntary. *

By checking below I certify that the responses provided above are true and accurate to the best of my knowledge and participation in this event is voluntary.

必填

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19 The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. Racer X Aquatics has put in place preventative measures to reduce the spread of COVID-19; however, Racer X Aquatics cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending practice could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending practice and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the practice may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Racer X Aquatics employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at practice or participation in Racer X Aquatics programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Racer X Aquatics, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Racer X Aquatics, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Racer X Aquatics program.

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