Cascade Swim Club COVID - 19 Screening Checklist

Completing this form before each practice will assist Cascade Swim Club in its efforts to ensure the safety of our membership, specifically our athletes, coaches, staff and families.
All swimmers and their families must respect the guidelines being set out by the club, our
facilities and our provincial and national governing bodies for this return to swimming to work.
By respectingng these guidelines you are respecting those that you will be swimming with in your
training cohorts (groups); the coaches and their families; as well as the facility staff who
will be ensuring we have a safe environment in which to train. The return to the pool will require
the honest and forthright approach to monitoring your own health and the health of those
around you as we venture back to the water.

Contact Information

Individual Filling Out Form:
Swimmer Name:
Your Swim Roster Group - PERFORMANCE *

Screening Questions


Does the person attending the activity, have ANY new onset of any of the below symptoms?

- Fever (Adult/ 18 and under core symptom)
- Cough (Adult/ 18 and under core symptom)
- Shortness of Breath / Difficulty Breathing (Adult/ 18 and under core symptom)
- Loss of sense of taste or smell (Adult/ 18 and under core symptom)
- Sore Throat (Adult core symptom)
- Painful swallowing
- Chills
- Runny Nose / Nasal Congestion
- Feeling unwell / Fatigued
- Nausea / Vomiting /and or Diarrhea
- Unexplained loss of appetite 
- Muscle / Joint Aches
- Headache
- Conjunctivitis (Pink Eye) *

Potential Exposure

Has the attendee tested positive for COVID-19 in the last 10 days or waiting for COVID-19 test results? *
Has the attendee had close contact* with a confirmed case of COVID-19 in the last 10 days? *
Face-to-face contact within 2 metres for 15 minutes or longer, or direct physical contact such as hugging
Does the attendee have a household member:

a) That is a close contact of a confirmed COVID-19 case and experiencing COVID-19 symptoms 
b) Scheduled to be tested for COVID-19
c) Awaiting a COVID -19 test result *

If you have answered “YES” to any of the above questions DO NOT participate. Contact your Club COVID19 Safety Officer and Representative. Go home and use the AHS Online Assessment Tool to determine if testing is recommended.

I understand my answers to be true and accurate. I understand answering falsely may impact the health and wellbeing of other teammates, their families, and coaches.
By submitting this document, I acknowledge that the Cascade Swim Club expectations and provisions outlined in the Cascade Return to Swim Document have been explained to me and I agree to adhere to them.
Signature *
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