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Skiatook Athletics COVID-19 Athlete Pre-screen
This form must be filled out prior to your first summer athletic activity with your respective sport.
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* Indicates required question
Email
*
Your email
Untitled Title
Full Name
*
Your answer
Sport
*
Your answer
Name of Parent/Guardian
*
Your answer
Phone number of Parent/Guardian
*
Your answer
Grade for the 20-21 School year
*
Choose
12th
11th
10th
9th
8th
7th
Please check boxes:
*
I understand that participating in summer athletic activities is voluntary.
I understand that I must provide my own water bottle during athletic activity
Required
BELOW ARE QUESTIONS REGARDING THE STUDENT-ATHLETE'S CURRENT HEALTH CONDITIONS:
Do you have chronic lung disease or moderate or severe asthma?
*
Yes
No
Do you have a serious heart condition?
*
Yes
No
Are you immunocompromised (cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications)?
*
Yes
No
Do you have diabetes?
*
Yes
No
Do you have a chronic kidney disease and undergoing dialysis?
*
Yes
No
Do you have liver disease?
*
Yes
No
CURRENT SYMPTOMS OF STUDENT-ATHLETE: Please check all boxes that apply to you the student athlete.
Check ALL that apply
*
Chills (associated with fever)
Repeated shaking or shivering with chills
Muscle pain
Cough
Sore throat
Headache
Shortness of breath
Loss of taste or smell
Diarrhea
NONE OF THE ABOVE
Required
If any of the above boxes where checked, please provide an explanation below.
Your answer
CURRENT SYMPTOMS OF HOUSEHOLD MEMBERS Please check all boxes that apply to all household members.
Check ALL that apply
*
Chills (associated with fever)
Repeated shaking or shivering with chills
Muscle pain
Cough
Sore throat
Headache
Shortness of breath
Loss of taste or smell
Diarrhea
NONE OF THE ABOVE
Required
If any of the above boxes where checked, please provide an explanation below.
Your answer
I agree to the following (please check all boxes)
*
I understand the above symptoms and affirm that I, as well as other household members, do not currently have, nor have experienced the symptoms listed above the last 14 days.
For the safety of our staff and other student-athletes, any person with a temperature above 100.4 will be sent home until they have no fever and no evidence of COVID-19 symptoms for 72 hours.
I affirm that I, as well as other household members, have not been diagnosed with COVID-19 within the last 30 days.
I affirm that I, as well as other household members, have not been knowingly exposed to anyone diagnosed with COVID-19 in the last 14 days.
I affirm that I, as well as other household members, have not traveled outside of the country or to any city other than our own that is or has been considered a "hot spot" for COVID-19 infections with the last 30 days.
Required
I, parent/guardian, agree and understand the information above ( please type in full name)
*
Your answer
Send me a copy of my responses.
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