X Entrant Health Survey

Entrant Information

Entrant Address

List Riders and Crew

Have you or any of your team or guests had any of the following symptoms in the last 14 days

 Fever above 100.4F
 Cough
 Shortness of breath
 Sore throat
 New loss of taste or smell
 None of the Above

Have you or anyone you have had contact with been diagnosed with COVID-19 in the last 14 days

 Myself
 A person I have had contact with
 A member of my team or guests
 None of the above

Have you or any of your team or guests been out of the United States in the last 14 days

 Yes No

If yes what country?

If yes, Have you self quarantined 14 days prior to the event

 Yes No

Are you or any of your guests or crew the age of 65

 Yes No

If you or any of your team or guests are over the age of 55 do you or any of your team or guests have any of the following pre-existing conditions

 Diabetes. Type 1 or 2
 Hypertension
 Cardiovascular Conditions. Coronary Artery Disease, Vascular Disease, Valvular Disease, Congestive Heart Failure
 Pulminary Coniditions. COPD, Asthma, Emphesema, Pulminary Fibrosis
 Immune Disorders of Suppression from the treatment of malignancy or autoimmune conditions
 Any other serious chronic medical conditions that could affect a person ability to fight infection
 None of the above

If you or any of your team or guests have any of these conditions above, do you or any of your team or guests have a doctors order clearing you to participate?

 Yes No