Gymnastic Dreams
COVID-19 Questionnaire
Parents/Guardians, please use this form every day before sending your child to their designated practice time. If you answer "YES" to two or more questions, you must keep your child home from Gymnastic Dreams. Thank you!
Sign in to Google to save your progress. Learn more
Gymnast Name: *
Date: *
MM
/
DD
/
YYYY
Parent Phone Number: *
Are you currently experiencing, or have you experienced in the past 14 days any of the following symptoms? *
No
Yes
Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)
Cough
Shortness of breath or difficulty breathing
Sore throat
Loss of smell or taste
Chills
Head or muscle aches
Nausea, diarrhea, vomiting
In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *
In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *
Have you been tested for COVID-19 and are waiting to receive test results? *
In the past 14 days, have you or any close contacts been on a commercial flight and traveled outside of Michigan? *
In the last 14 days have you had contact with someone who tested positive for COVID-19? *
In the last 14 days have you traveled or been in a place (city, state, local beach, over populated area, large gatherings or other) *
I've read each question and answered truthfully? *
I did read through each question and have not just selected all same answers to finish up questionnaire quickly? *
Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If “yes”, please provide a brief explanation.
I hereby certify that the responses provided above are true and accurate to the best of my knowledge. *
Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential. Any questions should be directed to Gymnastic Dreams front office only.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy