Non-Team Personnel Daily Health Screening

This Daily Health Screening Form is for Non-Team Personnel (IE - Officials, Event Staff, Etc...)

The submission must be completed the day of the event... Please be honest with your answers.  By answering 'YES' to any questions, you will be 'flagged' and removed from the event.

Thank you!

Victor Athletics (585) 924-3252,6306

HEALTH QUESTIONNAIRE

In the Past 10 Days... have you been Tested Positive / Waiting for Results for COVID-19, OR been DESIGNATED A CONTACT by a Local Department of Health?
In the Past 72 Hours... Have you Traveled to a Noncontiguous State, US Territory or CDC Level 2 and Higher Country?
Do you currently have (or has had in the last 10 days) one or more of these new or worsening symptoms listed BELOW?

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AFFIDAVIT

By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my hand written signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. I understand that checking the 'I AGREE' box above (OR verbally permitting a Victor Central Staff Member to on my behalf) constitutes a legal signature confirming that I understand, acknowledge, and warrant the truthfulness of the information provided in this document

You Will Receive a Confirmation Email... Please contact the Athletic Office 585-924-3252,6306 if you have any questions.

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