Heliyo Health Declaration

Date*

Athlete Name*

First Last

Phone*

Email*

Have you traveled internationally or have been in close contact with anyone who has traveled internationally within the last 14 days?*

Yes
No

Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*

Yes
No

Have you been directed to self-quarantine, or have had contact with anyone who has been directed to do so.*

Yes
No

Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem) [Temperature that defines a fever by CDC states 38C or 100.4F]*

Yes
No

Is the athlete listed above under 18 years of age.*

Yes
No

If athlete is under 18 years of ago a legal guardian will need to sign this form.

Legal Guardian Name

First Last

By Signing below I confirm the above information is correct*