Tusculum Coronavirus Questionnaire

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* 1. Please answer the following:

Participant Name

Name of Person Completing Survey (must be over 18)

Sport

Phone Number

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* 2. Have you been in contact with anyone or have YOU been diagnosed with or suspected of having coronavirus or COVID-19?

Yes

If yes, explain: (What were the dates of your illness or exposure? Were you hospitalized? Have you had a negative test since?)

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* 3. Have you recently developed any of the following? (Check box for "yes")

Fever or chills

Cough or shortness of breath

Sore throat

New loss of taste or smell

Diarrhea or vomiting

Unusual rash

Muscle aches

None of the above

If yes to any choices above, explain:

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* 4. Have you taken hyrdoxychloroquine or Plaquenil?

Yes

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* 5. Do you have moderate or severe ashthma? (Do you use your rescue inhaler almost every day to treat asthma attacks?)

Yes

If yes, explain:

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* 6. Do you have diabetes?

Yes

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* 7. Do you have a known heart condition?

Yes

If yes, explain:

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* 8. Are you living with or have regular contact with anyone suffering from the following? (Check box for "yes")

COPD including emphysema or chronic bronchitis?

Diabetes or severe obesity?

Serious heart condition including coronary artery disease or high blood pressure?

Kidney condition requiring dialysis

Immunocompromise from cancer treatment or HIV?

Chronic liver disease including cirrhosis?

Old age (85 or older)?

None of the above

If yes to any choices above, explain:

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* 9. What is your age, height, and weight?

Age:

Height:

Weight:

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* 10. Waiver and Release. You hereby release and forever discharge and hold harmless Tusculum University and its agents from any and all liability, claims and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from your or your minor child’s appearance on campus and/or participation in activities associated with the University. You understand that this release discharges the University from any liability or claim that you may have against the University with respect to any bodily injury, personal injury, illness, or other issue that may result from your or your minor child’s return and/or participation, whether caused by the negligence of the University or its officers, directors, employees, or other agents, or by the negligence of others, or by the condition of the facilities or areas where University activities are being conducted.

I have read and acknowledge the above terms and conditions

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* 11. Assumption of Risk. You further understand that your or your minor child’s appearance on campus and/or participation may expose him/her and others to unavoidable COVID-19 community spread. As such, you hereby expressly and specifically assume the risk of injury or other harm, and also expressly release the Tusculum University from all liability for injury, illness, or other issue resulting from or in any way related to your child’s return or participation.

I have read and acknowledge the above terms and conditions

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* 12. Detailed information on Tusculum's reopening measures can be found at www.tusculum.edu/reopening

I have read and acknowledge the above terms and conditions