1. During the past 14 days, have you experience symptoms of COVID-19, including fever, cough, or shortness of breath?
YesNo

2. During the past 14 days, have you been in contact with anyone with a suspected or diagnosed case of COVID-19?
YesNo

3. During the past 14 days, have you visited an area subject to a CDC Level 3 Travel Health Notice?
YesNo

4. Have you been exposed to any person who visited an area subject to a CDC Level 3 Travel Health Notice in the 14 days preceding the exposure?
YesNo

5. Have you received a COVID-19 Test within the last 60 days?
YesNo
If YES, when were you tested?

If YES, what were the results?

6. If you have received a positive COVID-19 test in the past 60 days, have you subsequently had your fever subside without use of fever-reducing medications?
YesNoN/A

7. If you have received a positive COVID-19 test in the past 60 days, have you subsequently had an improvement in your respiratory symptoms, such as cough and shortness of breath?
YesNoN/A

8. If you have received a positive COVID-19 test in the past 60 days, have you subsequently received two consecutive tests for COVID-19 RNA from respiratory specimens collected at least 24 hours apart? 
YesNoN/A

I acknowledge that I may be required to, and will agree to, complete this Questionnaire every day or at such frequency as shall be determined by the applicable club.

I hereby certify by signing below the the above answers are true and correct to the best of my knowledge. I hereby covenant and agree that if on the date of completing this Questionnaire or at any time thereafter, (a)the answer or more of Questions 1-4 is "Yes", or (B) I've tested positive for COVID-19 in the past 60 days and the answer to one ore more of questions 6-8 is "No", I will (X) immediately notify the Club regarding this, (Y) voluntarily refuse to participate in any Activities so long as t his is the case, and (Z)  not visit the Club's premises so long as this is the case.


Signature

Use your finger/stylus (mobile) or mouse (desktop) to sign below.



If you are a parent/legal guardian, please identify the name and age of the minor on whose behalf you are executing this Waiver of Liability and Release