Athlete Attestation Form U12B Athlete Attestation Form 2020-2021 Season U12B Athlete – First and Last Name * Date of Birth * Parent(s) or Guardian(s) – First and Last Name(s) * Phone * Email * PARENTS/GAURDIANS * YES NO In the last 14 days, have you or anyone you’ve had close contact with experienced any of the symptoms listed by Nova Scotia Public Health related to COVID19? * I.e Fever, cough, fatigue, nasal congestion, sore throat, headache, muscle aches, sneezing, hoarse voice, diarrhea, shortness of breath, loss of sense of smell or dark coloured lesions on hands and feet without any clear cause. PARENTS/GAURDIANS * YES NO In the last 14 days, have you or anyone you’ve had close contact with tested positive or been diagnosed by a healthcare provider with Covid-19 * PARENTS/GAURDIANS * YES NO In the last 14 days, have you or anyone you’ve had close contact with been instructed to self-isolate by a healthcare provider? *Due to a suspected exposure to a confirmed or probable COVID19 case. * PARENTS/GAURDIANS * YES NO In the last 14 days, have you or anyone you’ve had close contact with travelled outside of the Atlantic Provinces? NS, NB, PEI, NL. By submitting this form you acknowledge that you have answered honestly and truthfully to the best of your current knowledge and health status. If you are human, leave this field blank. Submit
