Western Maryland Chapter of US Lacrosse Covid Screening for Participants.
Girls High School League Spring 2021
* Required
Email address
*
Your email
Date of Activity you are participating in?
*
Choose
April 18th 2021
Location of Activity?
*
Choose
Frederick High School Stadium
First Name
*
Your answer
Last Name
*
Your answer
Current Grade
*
Your answer
Current School
*
Your answer
Phone Number
*
Your answer
Have you experienced any of the following symptoms in the past 48 hours:
*
Please select all that apply.
• fever or chills
• cough
• shortness of breath or difficulty breathing
• fatigue
• muscle or body aches
• headache
• new loss of taste or smell
• sore throat
• congestion or runny nose
• nausea or vomiting
• diarrhea
None of the above
Required
Current Temperature Reading?
*
Your answer
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who is known to have laboratory-confirmed COVID-19 or anyone who has any symptoms consistent with COVID-19?
*
Yes
No
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who has any symptoms consistent with COVID-19?
*
Yes
No
Are you isolating or quarantining because you may have been exposed to a person withCOVID-19 or are worried that you may be sick with COVID-19 or a positive COVID-19 test?
*
Yes
No
Are you currently waiting on the results of a COVID-19 test?
*
Yes
No
A copy of your responses will be emailed to the address you provided.
Submit
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