In-person activity compliance screener

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Please complete this each day your student will be participating in in-person athletic activities

Email *

Email address *

Student last name *

Student first name *

Name of parent/guardian completing form *

Date of practice *

YYYY

WWXC Pod *

Sole Sisters Pod (Meets at football fields on Grand Ave)

Sole Mates Pod (Meets at Regent and Highland)

Required

Has your child been exposed to anyone with COVID-19 in the past 10 days or been considered a Close Contact of someone with COVID-19 in the past 10 days? Here are the close contact details: https://www.dhs.wisconsin.gov/covid-19/close-contacts.htm *

Yes

Is your child experiencing any of these symptoms? Check all symptoms currently experiencing. (Any of these symptoms alone, even a runny nose or congestion, can be an indication of COVID-19, so it is important to stay home to avoid spreading illness to others. Students showing symptoms of illness at practice will be sent home.) Here is a full list of symptoms: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html *

Cough

Shortness of breath or problems breathing

Chills

Sore throat

Loss of taste or smell

Muscle pain or body aches

Headache

Fever (at or above 100.4 degrees F) or chills (or have they used a fever-reducing medications like Aspirin, ibuprofen, or Acetaminophen within the last 24 hours?)

Runny nose or nasal congestion

Nausea or vomiting

Diarrhea

No Symptoms

Required

Has your child tested positive for COVID-19 in the past 10 days? *

Yes

Send me a copy of my responses.

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