This form must be utilised to ensure that you are free from Covid-19 symptoms and pose a limited risk to others. It is important that once you have completed and signed this form that you send to or hand over to the person at your club or venue responsible for processing. To avoid virus transmission, an electronic version of the form is recommended and where possible sent back to the club via email or other electronic means.

All participants must have an active BJA licence. Review your licence By accessing the British Judo Association Membership portal

Note: parents/legal guardians of more than one sibling need to fill in a form per player.

Date*

Athlete’s Full Name*

First Name Last Name

Parent/Legal Guardian Name (if athlete is under 18)

First Name Last Name

Contact Details-Email*

example@example.com

Contact Details - phone number*

Are you currently diagnosed or believe to have Covid-19?*

NO YES

Do you currently display any of the following symptoms?*

Have you been in contact with a Covid-19 confirmed or suspected case in the previous 14 days**

NO YES Maybe

BJA Licence

Please add your BJA licence number

Confirm the following:*

I confirm that I have read the following statement: If you have answered YES to any of these questions you should stay at home and inform your coachand/or club Covid-19 contact person and medical practitioner.You should follow current UK Government Public Health guidelines. Only return to judo once youhave sought medical advice and considered not to be at risk of infecting others with Covid-19.

Signature of Member or Legal Guardian*

Clear

	YES	NO
High Temperature (Fever)
A New or continuous cough
Loss or change to your taste of smell
New unexplained shortness of breath

High Wycombe Judo Centre - Athlete Indemnity Form