CORONAVIRUS DISEASE (COVID-19) We encourage physical distancing, masking and good hygiene practices. CLINICAL CRITERIA: Are you experiencing any of these symptoms? (Only tick those that apply, if none apply then leave blank!) Fever or chillsDifficulty breathing or shortness of breathTight ChestNew or worsening coughSore ThroatLoss of a sense of smell or tasteBody aches or weaknessVomiting or diarrheaDizziness or light headednessSevere headaches Chronic or Pre-existing conditions: I am aware that having any of the following pre-existing conditions puts me at a high risk should I contract COVID-19; Asthma or chronic lung disease Pregnancy Diabetes Kidney failure Liver disease Weakened immune system or an auto-immune disease Heart condition High blood pressure Extreme obesity etc. Close contact: (Only tick those that apply, if none apply then leave blank!) I live with someone who has COVID-19I have had close contact with someone who has COVID-19 during the past 10 daysI have been in contact with someone who has respiratory symptoms (e.g. cough,sore throat, shortness of breath) during the past 10 days The information is accurate to my best knowledge and I undertake to inform the Committee should any of the above information change. Player Name and Surname Signature or Guardian in case of minor - Mouse left click and drag in signature field to sign your signature Date
