Western Maryland Chapter of US Lacrosse Covid Screening for Participants.

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Girls High School League Spring 2021

Email *

Date of Activity you are participating in? *

Location of Activity? *

First Name *

Last Name *

Current Grade *

Current School *

Phone Number *

Have you experienced any of the following symptoms in the past 48 hours: *

Please select all that apply.

• fever or chills

• 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

None of the above

Required

Current Temperature Reading? *

Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who is known to have laboratory-confirmed COVID-19 or anyone who has any symptoms consistent with COVID-19? *

Yes

Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who has any symptoms consistent with COVID-19? *

Yes

Are you isolating or quarantining because you may have been exposed to a person withCOVID-19 or are worried that you may be sick with COVID-19 or a positive COVID-19 test? *

Yes

Are you currently waiting on the results of a COVID-19 test? *

Yes

A copy of your responses will be emailed to the address you provided.

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