BDHS Athletics COVID-19 SELF ASSESSMENT FORM

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Please fill this out within 24 hours of your return to Athletics for your first practice or after an extended break.

Email *

Today's Date: *

YYYY

Student's Name: *

Parent/Guardian's Name: *

Sport: *

Baseball

Boys Basketball

Girls Basketball

Cheer

Cross Country

Football

Boys Golf

Girls Golf

Boys Soccer

Girls Soccer

Softball

Swimming

Boys Tennis

Girls Tennis

Track and Field

Boys Volleyball

Girls Volleyball

Water Polo

Have you had a temperature of over 100.4℉ in the last 24 hours? *

Yes

Have you had any of the following symptoms in the last 24 hours? If not, answer "No". *

Fatigue

Cough

Difficulty breathing/Shortness of breath

Muscle or body aches

Headaches

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

Required

Have you traveled outside of the country within the past 14 days? *

Yes

Have you been in close contact with anyone known or suspected to have the COVID-19 coronavirus illness in the last 14 days? *

Yes

I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE, ACCURATE, AND COMPLETE. I ALSO CERTIFY THAT IF AT ANY POINT, I CAN ANSWER YES TO ANY OF THE ABOVE QUESTIONS, I WILL IMMEDIATELY NOTIFY A COACH OR ADMINISTRATOR AND WILL STAY HOME UNTIL I CAN ANSWER NO TO ALL OF THE ABOVE QUESTIONS. I acknowledge the above *

Yes

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

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