Initial Screening Form to Restart Marching Band
UCPS will be using the form designed by the NCHSAA to pre-screen all students returning to sports and marching band. The form is shown below and all answers will be captured electronically.

In addition, UCPS is asking all students and adults returning to activities during the summer of 2020 to sign a Waiver/Release for Communicable Diseases including COVID-19. This form is captured electronically below.
Participant Name (if not a student, please write "volunteer" next to your name *
LAST NAME, FIRST NAME
Since January 1, 2020 have you been told that you have had a positive test for COVID-19, OR have you been told by a Doctor, Physician Assistant or Nurse Practitioner that you had to quarantine (stay home) due to concern that you had COVID-19 symptoms? *
Today or in the past 2 weeks have you had any of the following symptoms: *
YES
NO
A fever (temperature more than 100.4º Fahrenheit or 38º Celsius)?
Shaking chills?
A new or worsening cough, shortness of breath or difficulty breathing?
Racing heart, heart skipping beats or fluttering of the heart?
Unusual dizziness, particularly with exercise?
Fatigue or difficulty with exercise?
A sore throat different than associated with seasonal allergies?
New loss of taste or smell?
Nausea, vomiting or diarrhea?
Do you have anyone in your household who has been diagnosed with COVID-19 in the past 14 days?
Have you been in contact with anyone infected with COVID-19 in the past 14 days?
By signing this document, I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Student Signature - Please type your full name. *
By providing your electronic signature below, you agree that this can be used in the same manner as a physical signature.
Parent/Legal Guardian Signature - Please type your full name. *
By providing your electronic signature below, you agree that this can be used in the same manner as a physical signature.
Date *
MM
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DD
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YYYY
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