DSA Daily Health Screening
This daily survey is for parents/guardians with swimmers under the age of 18 and swimmers/coaches over the age of 18, to be completed at least one hour before and no more than 12 hours before your designated practice start time. This survey must be completed on time for each practice, or you will not be allowed on the pool deck.
Sign in to Google to save your progress. Learn more
Email *
Name of Person Entering Lowry-First/Last *
For Meet/Practice on this Date *
MM
/
DD
/
YYYY
Practice Group *
Pool *
1. Have you or any of your family members experienced any of the following symptoms in the past 72 hours? Chills, Repeated Shaking with Chills, Shortness of Breath or Difficulty Breathing, Fatigue, Muscle or Body Aches, Headache, New Loss of Taste/Smell, Sore Throat, Congestion or Runny Nose, Nausea or Vomiting, Diarrhea *
2. Have you or your family members had any signs or symptoms of a fever in the past 72 hours, such as chills, sweats, felt "feverish," or had a temperature that is elevated for you (or 100.4F or greater)? *
3. Have you traveled internationally or been on a cruise in the last 14 days? Or, have you had any close contact in the last 14 days with someone with a diagnosis or presumptive positive of COVID-19? *
Signature: By entering your name here, you are agreeing that all of the above answers are truthful. This is an electronic Signature:                                                                                                                  Parent or Swimmer(18 or Over) *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Denver Swim Academy. Report Abuse
Google Forms