Healthy Swimming Checklist Please complete this for the adult and the swimmer intending to attend the lessons. Health Survey 1. Within the last 10 days, have you been diagnosed with COVID-19 or had a test confirming you have the virus? * YES NO 2. Within the last 10 days, have you been in contact with someone who has Covid-19? * YES NO 3. Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by another reason? * YES NO 4. Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by another reason? Fever, Chills, or Repeated Shaking/Shivering Cough Sore Throat Shortness of Breath, Difficulty Breathing Feeling Unusually Weak or Fatigued Loss of Taste or Smell Muscle pain Headache Runny or congested nose Diarrhea * YES NO Name * First Last Name * Last Phone * Email * Lesson Location: Pool Location Time: Lesson Time If you answer “yes” to any of the questions above we recommend you consult your family physician to get tested and please contact us again when you are ready to start your lessons. Submit
