Step 5: COVID Attestation Form - Bourne High School

Step 5: COVID Attestation Form


Athlete Name:	*

Date:	*

	* 1. Have you been tested for active COVID19 virus (nasal/throat swab or saliva test)?
		Yes
		No

If YES: Date tested:	*

	* Result:
		Positive
		Negative
		Awaiting results
		N/A

	2. Do you currently have any of the following symptoms that are not explained by another medical condition (check those that apply):
		Fever
		Cough
		Shortness of breath or difficulty breathing
		Chills
		Muscle pain
		Sore throat
		New loss of taste or smell
		N/A

	* 3. Have you or any of your immediate household been in prolonged close contact* with anyone confirmed or presumed positive for COVID-19 in the past 14 days? *Close contact is defined as less than 6 feet distance for greater than 15 minutes
		Yes
		No

	* 4. Have you traveled out of state within the last 14 days?
		Yes
		No

	* If yes: a. Travel within the united states?
		Yes
		No
		N/A

If YES: Which state**?	*

(Put N/A if not applicable)

Date of return?	*

(Put N/A if not applicable)

	* **Is the state returned from under travel restriction?
		Yes
		No
		N/A

	* b. Internationally?
		Yes
		No

	* 5. Have you, or any of your immediate household, been asked to quarantine (due to travel, illness, exposure) by state/ county mandates/ guidance, a health care practitioner, the CDC or DOH in the past 14 days?
		Yes
		No



I attest the information provided is accurate and honest.

Signature:	*

Date:	*

Signature (parent/guardian):	*

Date:	*

Send a copy of the completed form to this email address :

* Indicates Required fields.