SWAMPSCOTT HIGH SCHOOL ATHLETICS

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This self- certification must be completed before every game/practice. You are attesting that these questions have been answered truthfully.

IF YOU HAVE ANY SYMPTOMS RELATED TO COVID-19 YOU MUST NOTIFY YOUR COACH/ATHLETIC TRAINER IMMEDIATELY

Email *

First name last name *

Todays Date *

YYYY

What Sport are you participating in *

Baseball

Track and Field

Softball

Tennis

Girls Lacrosse

Boys Lacrosse

Powder Puff

In the past 72 hours have you experienced any of the following symptoms below *

yes

have you measured a body temp above 100 degrees

have you experienced shortness of breath or trouble breathing

In the past 72 hours, have you experienced any of the following symptoms associated with COVID-19? *

yes

Cough

Loss of taste or smell

Fatigue

Headache

Muscle or body aches

Sore throat

Nasal congestion/ runny nose

Nausea or vomiting

Shortness of breath

In the past 14 days, have you had close contact with an individual diagnosed with COVID-19? "Close contact" means: living in the same household as a person who has tested positive for COVID-19 OR caring for a person who has tested positive for COVID-19. *

Yes

In the past 14 days, have YOU OR ANY CLOSE CONTACTS been asked to self-isolate or quarantine by your doctor or a public health official? *

Yes

Attestation *

I attest that the information above is accurate to the best of my knowledge.

Electronic Signature (First and Last name) *

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

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