Member Positive COVID Form - Use this form to submit a report that your child is a close contact as a result of out of Club exposure.

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Email *

First and Last Name Parent or Caregiver Completing this Form *

Address *

Best Parent/Caregiver preferred email *

parent preferred phone *

Child's First and Last Name *

Child's date of birth *

YYYY

Program your child is enrolled in: *

Preschool- Classroom A

Preschool- Classroom B

Preschool Classroom C

Before School

After School

Athletics - Basketball

Aquatics- Sea Lions

Other

Other:

Date of last exposure to Covid positive individual *

YYYY

Relation of COVID positive case to your child *

Household member (Note: if the household member is a sibling that also attends the Club, please complete the COVID positive form as well.)

Non-household member

If the Covid positive individual is a household member, please provide the following: First & Last Name:

If the COVID positive individual is a household member, is the individual able to completely isolate from your child?

Yes

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Vaccination status of child *

fully vaccinated (with booster if qualify)

not vaccinated or fully vaccinated

Date Last at Club *

YYYY

Any additional information that may be helpful to share with us:

Submit

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