Esports Event Participant Health Disclosure
Participant Information
Full Name
Date of Birth
Team / Organization (if any)
Contact Information
Email
Phone Number
Emergency Contact Name
Emergency Contact Phone
Medical Information
Do you have any medical conditions that event organizers should be aware of?
Allergies (including medication, food, etc.)
Are you currently taking any medication?
Recent Symptoms and Exposure
In the last 14 days, have you experienced any of the following? (select all that apply)
Fever
Cough
Shortness of Breath
None of the above
Have you been in close contact with anyone diagnosed or suspected of having a contagious illness in the last 14 days?
No
Yes
Additional Information
Any other information you'd like the event organizers to know?
Signature
Date