BCIT Medford Athletic COVID-19 Screening Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form must be completed prior to arriving on campus for practices/games.

Any of the symptoms below could indicate a COVID-19 and may put your child at risk for spreading illness to others. Please note that this list does not include all possible symptoms and children with COVID-19 may experience any, all, or none of these symptoms. Please check your child daily for these symptoms.

What sport do you play? *

Varsity Softball

Varsity Baseball

Student ID number *

First Name *

Last Name *

SECTION A- IF TWO or MORE of the fields in this section are checked off, please keep your child home and notify the school nurse for further instructions. *

Fever (measured or subjective)

Chills

Rigors (shivers)

Myalgia (muscle aches)

Headache

Sore Throat

Nausea or Vomiting

Diarrhea

Fatigue

Congestion or Runny Nose

None of the above symptoms

SECTION B- IF AT LEAST ONE field in this section is checked off, please keep your child home and notify the school nurse for further instructions. *

Cough

Shortness of Breath

Difficulty Breathing

New Loss of Smell

New Loss of Taste

None of the above symptoms

Please verify if: *

Your child has had close contact (within 6 feet of an infected person for at least 10 mins) with a person with confirmed COVID-19

Someone in your household is diagnosed with COVID-19

Your child has traveled to an area of high community transmission

None of the above

On most (but not all) school days, a 5:00pm late bus will be available for student-athletes. Due to COVID-19 and our priority to keep our students safe and socially distanced, it is important we have an accurate count of who will need the bus on a given day. For those students who are requesting to ride the late bus, this form must be submitted by 10:00am. Will your child need the 5:00pm late bus today? *

Yes

Select "Yes" in the dropdown to verify that all information on this form is correct to the best of your knowledge. *

Yes

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of BurlCoSchools. Report Abuse

Forms