COVID-19 Derry Athletics Voluntary Workout Survey and Waiver of Liability
1. This form must be completed prior to participating in voluntary workouts.
What sport is your child participating in this Fall? *
Parent/Guardian Name and Phone Number *
Student Name(s) *
Grade *
Have you, your child, or someone in close contact with you been tested positive for COVID-19 in the last fourteen days? *
In the last fourteen days, have you or anyone in close proximity to you experienced symptoms consistent with COVID-19 such as shortness of breath, fever, or coughing? *
Does your child have any pre-existing conditions that would classify him/her as a high-risk individual if they would happen to contract COVID-19?
Clear selection
By typing your name below, you are verifying that you are the legal parent or guardian of the student(s) listed on this form. Additionally, you are acknowledging and releasing the Derry Area School District, all associated entities, and employees of liability and responsibility in the event that you, your child, or anyone associated with you contract COVID-19 from any events, practices, gatherings, etc., held by the Derry Area School District. *
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