Detroit Catholic Central Screening Form

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This form is to be filled out prior to participating in on-campus athletic activity

Last Name *

First Name *

Best number to reach a parent or guardian (include name of parent/guardian) *

Grad Class *

SPORT(S); check all that apply *

COACH

Baseball

Basketball

Boardercross

Bowling

Cross Country

Football

Golf

Hockey

Lacrosse

Rugby

Skiing

Soccer

Swimming

Tennis

Track & Field

Wrestling

Other:

Required

People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. HAVE YOU RECENTLY EXPERIENCED ANY OF THESE SYMPTOMS (check all that apply): *

Fever or chills (temp of 100.3 or higher)

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

I HAVE NOT RECENTLY EXPERIENCED ANY OF THESE SYMPTOMS

Required

Have you had close contact with or cared for someone with a confirmed case of COVID-19 in the last 24 days? *

Yes

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