COVID-19 Student-Athlete/Coach Self-Screening
This form must be completed every day as part of your at home, self-screening.

If ALL of the BELOW are NO, then the student-athlete/coach may enter the workout area for volunteer summer activities.
If you answer YES to any of the questions, you should stay home, care for yourself and contact your health care provider with worsening symptoms.
Email address *
What is your Sport/Activity? *
Required
Today's Date *
MM
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DD
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YYYY
First and Last Name (Do not use nicknames) *
Do you have a NEW or WORSENING cough OR shortness of breath? *
Do you have at least two of the following symptoms: Fever (>100), chills, muscle pain, headache, sore throat, new loss of taste/smell *
Emergency contact name for TODAY: *
Emergency contact phone number for TODAY: *
A copy of your responses will be emailed to the address you provided.
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