COVID-19 Health Disclosure
This form is to be completed by all sports team members prior to participation in team activities.
Personal Information
Full Name
Team
Date
Symptom Check
In the past 14 days, have you experienced any of the following symptoms?
Fever
Cough
Shortness of breath
Loss of taste or smell
None
Exposure History
Have you had close contact with anyone diagnosed with COVID-19 in the past 14 days?
Yes
No
Travel History
Have you traveled internationally or to any COVID-19 hot spots within the last 14 days?
Yes
No
Additional Comments or Details
Signature
Date