COVID-19 Michigan Meet of Champs Health Screening Form (Form will be LIVE on Saturday, November 14th @ 4:00AM)
If you answer "yes" to any of the symptoms in Section 1
If you answer "yes" to two (2) of the symptoms in Section 2
If you answer "yes" to the Close Contact question in Section 3
THEN - You are not allowed to attend the Michigan Meet of Champs. You should self-isolate at home, and contact your primary care physician's office for direction.
Person Filling Out Form First Name
Person Filling Out For Last Name
First and Last Names of Other Parties with you.
SECTION 1 - In the last 24 hours have you or anyone in your party experienced:
Fever of 100.4 or greater not explained by a known medical or physical condition
Uncontrolled cough not explained by a known medical or physical condition
Shortness of breath not explained by a known medical or physical condition
None of the above
SECTION 2 - In the last 24 hours have you of anyone else in your party experienced:
Loss of smell or taste not explained by a known medical or physical condition
Muscle aches (myalgia) not explained by a known medical or physical condition
Sore Throat not explained by a known medical or physical condition
Severe Headache not explained by a known medical or physical condition
Diarrhea no explained by a known medical or physical condition
Vomiting not explained by a known medical or physical condition
Abdominal pain not explained by a known medical or physical condition
None of the above
SECTION 3 - In the past 14 days have you or anyone else in your party had "close contact" with an individual diagnosed with COVID-19?
Waiver – Michigan Meet of Champions - In consideration of you accepting this entry, I, the participant, intending to be legally bound do hereby waive and forever release any and all right and claims for damages or injuries that I may have against the Event Director, and all of their agents assisting with the event, Michigan Interscholasitc Track Coaches Association (MITCA) Executive Board or its members, RunSignUp.com, Freeland Public Schools and any of its administration and employees, property owners of located event, sponsors and their representatives, volunteers and employees for any and all injuries to me or my personal property. This release includes all injuries, any and all Covid-19 related contraction and illness, and/or damages suffered by me before, during or after the event. I recognize, intend and understand that this release is binding on my heirs, executors, administrators, or assignees.I know that running a cross-country race is a potentially hazardous activity. I should not enter and run unless I am medically able to do so and properly trained. I assume all risks associated with running in this event including, but not limited to: falls, contact with other participants, the effects of weather, traffic, and course conditions, and waive any and all claims which I might have based on any of those and other risks typical found in running a road race. I acknowledge all such risks are known and understood by me. I agree to abide by all decisions of any race official relative to my ability to safely complete the run. I certify as a material condition to my being permitted to enter this race that I am physically fit and sufficiently trained for the completion of this event and that a licensed Medical Doctor has verified my physical condition.In the event of an illness, injury or medical emergency arising during the event I hereby authorize and give my consent to the Event Director to secure from any accredited hospital, clinic and/ or physician any treatment deemed necessary for my immediate care. I agree that I will be fully responsible for payment of any and all medical services and treatment rendered to me including but not limited to medical transport, medications, treatment and hospitalization.By submitting this form, I acknowledge (or a parent or adult guardian for all children under 18 years) has read and agreed to the above release and waiver. I also confirm that by signing this waiver I am attending this event in full knowledge that myself and all of my designees submitted on this form are currently COVID-19 negative, show no symptoms of having COVID-19 and have answered all questions on the provided form truthfully.Further, I grant permission to all the foregoing to use my name, voice and images of myself in any photographs, motion pictures, results, publications or any other print, videographic or electronic recording of this event for legitimate purposes.
I have read and agree to the terms of this waiver.
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This form was created inside of Freeland Community Schools.