LAC Covid-19 Questionnaire
By completing this form you are voluntarily providing health-related information for yourself or your minor child.  LAC will not use this information for any purposes other than reporting.  This information is for the sole purpose of accessing the current situation so that it may act in accordance with approved LAC COVID-19 Procedures.  
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Phone Number *
Swimmer(s) Name(s) (First and Last) *
Parent/Guardian Name (First and Last) *
Provide the last known date of contact with individual that tested positive for COVID (or test date if self). *
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Has your child had a fever or any other symptoms of COVID in the last 48 hours? *
If your child has taken a viral COVID test, please indicate if the result was negative or positive? *
Required
If your child has taken a viral COVID test, please provide most recent test date.
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Provide additional details that you feel will better clarify your child's situation related to COVID-19 close contact (school, home, etc.) or quarantine. *
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