WAC COVID-19 Weekly Self-Screening Questionnaire
This form will take about one minute to complete and will ask you a series of questions about your swimmer's health and contact with others so that he/she can be given access to our facilities. Questionnaires should be answered on the Sunday prior to each week of practice. Families with more than one swimmer should only complete one form unless answers differ between siblings.
FAILURE TO COMPLETE THIS FORM WILL RESULT IN YOUR SWIMMER BEING DENIED ACCESS TO ANY WAC FACILITY.
Thank you for your cooperation and understanding!
Please list your swimmer(s) first and last name.
Is your swimmer experiencing any of the following COVID-19 symptoms?
A fever (100.4° or higher) or feel feverish.
Shortness of breath or difficulty breathing that cannot be attributed to another health condition or specific activity (such as physical exercise).
A cough that is new or out-of-the-ordinary.
Any flu-like or other COVID-19 symptoms that cannot be attributed to another health condition or specific activity (such as physical exercise).
Other COVID-19 symptoms such as: chills, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion, runny nose, nausea or vomiting, or diarrhea.
None of the above.
Has your swimmer been diagnosed with COVID-19 or had close unprotected contact with a confirmed or probable case of COVID-19 within the last 14 days? For this question, "close" is defined as less than 6 feet for a prolonged period of time.
Has your swimmer traveled internationally or taken a cruise in the last 14 days?
I hereby provide the following data on behalf of my child, which I certify to be correct to my knowledge and belief, and consent to its use by WAC and its affiliates and their respective service providers to the extent necessary to assess, independently and/or in collaboration with governmental authorities, whether WAC, in its sole discretion, considers it appropriate to admit my swimmer to WAC's facilities in light of the current COVID-19 pandemic. I understand that this data may be shared with governmental authorities, healthcare providers, and service providers that WAC deems appropriate, and that it shall use reasonable precaution to protect this data from use outside of its intent.
I disagree (checking this box will automatically prevent your swimmer from entering any WAC facility).
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