SURGE Wellness Screening & Participation Consent Form
Thank you for your support and patience during these ever-changing times. We are excited to get back on the courts in the safest possible way for all. Part of the steps includes the attached Wellness Screening and Participation Consent that we are requiring prior to EVERY EVENT. Please call or email the the club director if you have any questions
Email *
Date of Birth *
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DD
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Player Name *
1st Attendee First Last Name, if needed
2nd Attendee First Last Name, if needed
Player Team *
In the last 14 days, have anyone listed on this form (or any member of the household) had any of the following? *
Yes
No
Difficulty breathing or shortness of breath
Pressure, tightness, persistent pain in chest
Loss of smell
Travel by boat of plane
Has anyone listed on this form had any of the following within the last 14 days: *
Yes
No
Diagnosis of COVID-19 infection or any other communicable disease
Waiting on results of test for COVID-19 infection
Symptomatic but not tested for COVID-19
Has anyone listed on this form or close contact have been diagnosed with COVID-19 infection, when did that occur?
MM
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DD
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YYYY
If the answer to any of these questions changes before the my event, I agree to notify Surge Volleyball as soon as possible. Any "YES" answers will require me to miss my next scheduled event. *
I understand that I must sign, print and submit all required waivers to participate in any Surge hosted event. *
In order to do our due diligence, we will not allow spectators in the gym or around our courts in the parks. Only the players may be in the gym or on/around the courts in the parks. We ask that all players arrive no more than 15 minutes before scheduled event and to depart within 15 minutes of the conclusion of their event. *
Participation Consent: Please be assured that we are taking all the necessary steps set forth by the CDC and state for sterilization and sanitation. However, it is possible to contract COVID-19 (or any other communicable disease) in any public space. Our gym will provide for socially distant rules and steps to enhance our level of safety. However, due to the nature of playing the sport of volleyball, a 6 foot distance is not always possible between the players. Reopening social aspects comes with some risks that we all must weigh, but we also want you to feel confident that our club is taking every step to keep our patients and staff safe during this difficult time. Clicking "yes" below indicates that the risks involved are accepted, and that consent is given for participation and instruction to be provided by the coaches, staff and officers of Surge Volleyball Club. *
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