COVID-19 Pre-Participation Questionnaire If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required First Name * Last Name * Age * Grade * 9 10 11 12 Sports * Are you currently free from illness? * YesNo Do you have a history of pneumonia? * YesNo During your time away from Cathedral Catholic High School, did you have, or do you currently have any of the following: Symptom Duration Explanation (if marked yes) Fever * YesNo Duration Explanation Chills * YesNo Duration Explanation Extreme Fatigue * YesNo Duration Explanation Cough * YesNo Duration Explanation Pain/Difficulty Breathing * YesNo Duration Explanation Shortness of Breath * YesNo Duration Explanation Body Aches * YesNo Duration Explanation Sore Throat * YesNo Duration Explanation Loss of Taste/Smell * YesNo Duration Explanation Change to Vision/Eye Discharge * YesNo Duration Explanation Diarrhea * YesNo Duration Explanation Unexplained Headache * YesNo Duration Explanation 2-14 days before having these symptoms, did you have a suspected exposure to COVID-19? * YesNo Have you previously been or are you currently diagnosed with COVID-19? * YesNo Have you been around anyone who has a suspected or confirmed case of COVID-19? * YesNo If marked yes to any above, please give dates of diagnoses/exposure: Please list any countries/states/cities you have visited outside of San Diego since March 15, 2020 and dates you were there: 1. Dates 2. Dates 3. Dates 4. Dates 5. Dates Assumption of Risk and Agreement As a parent/guardian, I understand that those participating in athletics are at a higher risk of exposure to the COVID-19 virus; due to increase physical contact, shared equipment, and ventilation. In order to participate in sports, the student-athlete and parent/guardian of the student-athlete must read and sign the following assumption of risk and waiver. As a parent/guardian, I understand that COVID-19 is extremely contagious and has been declared a worldwide pandemic by the World Health Organization. As a parent/guardian, I understand that by participating in sports and by utilizing the associated facilities my child may knowingly, or unknowingly transmit the virus to family, friends, teammates, and/or others he/she may come into contact with. Which may include the elderly, immunocompromised, young children, and others that are at higher risk to contract the virus. As a parent/guardian, I understand that there is an increase in exposure during contests/games and during travel to said contests/games. As a parent/guardian, I understand that although every attempt is made to minimize chances of exposure, there is no guarantee that can be made. To do my part to limit the exposure to/transmission of COVID-19, I, as a parent/guardian, agree that my child will follow the recommendations of the CDC which include, but are not limited to: Proper general hygiene Proper handwashing techniques Use of hand sanitizer when handwashing is unavailable Proper use of personal protective equipment Not sharing any personal items As a parent/guardian, I voluntarily agree to assume all risks and accept sole responsibility for any injury to my child. I hereby release, covenant not to sue, discharge and hold harmless Cathedral Catholic High School, their administration, staff, volunteers, employees, other participants, sponsoring agencies, with respect to any and all injury, illness, or disability, loss or damage to person or property, expenses, and/or death; arising out of or relating to COVID-19. I understand this release includes any claims based on actions, omissions, or negligence of the releases, and whether a COVID-19 infection occurs before, during or after my participation. In the interest of health and public safety during the COVID-19 pandemic, I acknowledge that I have truthfully and accurately disclosed the above information regarding my child’s health status and history, including any symptoms/exposure to COVID-19. Student Signature * Parent/Guardian Signature *
