Marian Swim and Dive Screening form

Name *

Have you had a cough in the last 24 hours *

Yes

No

Have you had shortness of breath in last 24 hours *

Yes

No

Have you had a sore throat in the last 24 hours *

Yes

No

Have you had a fever of over 100.3 in the last 24 hours *

Yes

No

Have you had close contact, or cared for someone with a confirmed case of COVID-19 in the last 24 hours? *

Yes

No

Emergency Contact Name

Emergency Contact Number