Atlantis COVID-19 Practice Entry Questionnaire
Please answer the following question before leaving your car.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Within the last 14-days, have you experienced a new cough that you cannot attribute to another health condition? *
Within the last 14-days, have you experienced new shortness of breath that you cannot attribute to another health condition? *
Within the last 14-days, have you experienced new shortness of breath that you cannot attribute to another health condition? *
Within the last 14-days, have you experienced a new sore throat that you cannot attribute to another health condition? *
Within the last 14-days, have you experienced new muscle aches that you cannot attribute to another health condition or a specific activity such as physical exercise? *
Within the last 14-days, have you had a temperature at or above 100.0° or the sense of having a fever? *
Within the last 14 days, have you had close contact, without the use of appropriate PPE, with someone who is currently sick with suspected or confirmed COVID-19?* (Note: Close contact is defined as within 6 feet for more than 10 consecutive minutes) *
Within the last 48-hours, have you had Diarrhea? *
BY ATTENDING OR PARTICIPATING IN THIS COMPETITION, YOU VOLUNTARILY ASSUME ALL RISKS ASSOCIATED WITH EXPOSURE TO COVID-19 AND FOREVER RELEASE AND HOLD HARMLESS USA SWIMMING, MICHIGAN SWIMMING, BIRMINGHAM BLOOMFEID ATLANTIS, AND CRANBROOK SWIM CLUB AND EACH OF THEIR OFFICERS, DIRECTORS, AGENTS, EMPLOYEES OR OTHER REPRESENTATIVES FROM ANY LIABILITY OR CLAIMS INCLUDING FOR PERSONAL INJURIES, DEATH, DISEASE OR PROPERTY LOSSES, OR ANY OTHER LOSS, INCLUDING BUT NOT LIMITED TO CLAIMS OF NEGLIGENCE AND GIVE UP ANY CLAIMS YOU MAY HAVE TO SEEK DAMAGES, WHETHER KNOWN OR UNKNOWN, FORESEEN OR UNFORESEEN, IN CONNECTION WITH EXPOSURE, INFECTION, AND/OR SPREAD OF COVID- 19 RELATED TO PARTICIPATION IN THIS COMPETITION. *
Temperature Reading Today *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms