2021-2022 Athlete Attestation Form

The health, safety and the wellbeing of our Athletes, Coaches and families are of upmost priority to Express Basketball Club. Each practice or game all athletes are required to submit a short survey attesting to their current wellness and potential exposure to Covid-19. Please review and submit this form before you come to any gym sessions. If you answer “yes” to any of these questions PLEASE do not attend the practice or game that day. If you answer “no” to all question please proceed to the practice or game.

In the event you test positive for Covid-19 please notify us immediately so we can do contact tracing and notify anyone who may be affected or had close contact with you. Also AT ANY TIME during a session if you begin to feel unwell at all, please let the coach know immediately.

Athlete Attestation Form 2020-2021 Season

Athlete – First and Last Name *

Date of Birth *

Parent(s) or Guardian(s) – First and Last Name(s) *

Phone *

Email *

PARENTS/GUARDIANS *

YES

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, shortness of breath, etc. *

PARENTS/GUARDIANS *

YES

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/GUARDIANS *

YES

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/GUARDIANS *

YES

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.

If you are human, leave this field blank.