Pre-Activity Form

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Pre-Activity Form

Please take a moment to fill out this health questionnaire at least 1 hour before practice each day. Please be sure to answer these honestly. Our #1 concern is the health of you and your teammates. Missing a few practices is minimal to potentially infecting teammates and their families. We appreciate it!

Please be sure to bring your own MASK, LABELED WATER BOTTLE, HAND SANITIZER and OTHER EQUIPMENT. Items MAY NOT be shared among athletes for your safety.

Athletes MUST maintain a minimum distance of 10 feet between each other at all times.

Name - First & Last *

Temperature at Arrival to Practice

DO NOT ANSWER - (This will be filled in by coach at practice)

Have you had a fever within the past 24 to 48 hours? *

Yes

Have you had a consistent cough at any time within the past 24 to 48 hours? *

Yes

Have you had any shortness of breath at any time within the past 24 to 48 hours? *

Yes

Have you had any nasal congestion, a runny nose, or a loss of smell or taste at any time within the past 24 to 48 hours? *

Yes

Have you had a sore throat or any other cold/flu-like symptoms at any time within the past 24 to 48 hours? *

Yes

Have you had any gastrointestinal symptoms, including nausea, vomiting, or diarrhea (not associated with another health condition) at any time within the past 24 to 48 hours? *

Yes

Have you had any muscle fatigue or soreness or any other signs of illness at any time within the past 24 to 48 hours? *

Yes

Have you had any contact with a person who has been diagnosed with COVID-19 (a positive test result) within the last 14 days? *

Yes

Have you had any contact with a person who was suffering from a respiratory illness within the last 14 days? *

Yes

Have you traveled to an area of the country, or outside the country, that is considered a 'hot spot' currently for COVID-19 within the last 14 days? *

Yes

I acknowledge that I have answered these questions to the best of my ability. I understand that if I show signs or symptoms of potential respiratory illness, or if I have a fever that I will be required to return home and may not stay on LCPS campus.

Please type your full name which will serve as your Electronic Signature.

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