Teen - Wellness Check In (Bloomingdale Church)
In order to attend onsite teen programming, you must complete this wellness check in.

Please complete form from your home before coming to the program, preferably at least 30 minutes before the start of the program.
Your Name (Teen) *
*If your answer YES to any of the questions, please stay home.
Do you currently have a temperature 100 degrees or higher? *
Please confirm by taking your temperature.
Have you had a 100 degree fever or higher in the past 24 hours, or taken any symptom reducer? *
Symptom reducer examples (to reduce fever): Tylenol, Ibuprofen, cough suppressant, Imodium
Have you, or anyone living in your home, experienced any of the following symptoms in the past 24 hours: Fever, chills, cough, shortness of breath or difficulty breathing, headache, sore throat, recent loss of taste or smell, nausea, vomiting, or diarrhea? *
Have you, or anyone living in your home, had a close contact++ in the last 14 days with someone with a diagnosis of COVID-19? *
++A "Close Contact" is someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated. Anyone considered a close contact to someone who has been identified as positive for the virus may not attend for 14 calendar days.
Model the 3 W's - Wear a mask, Watch distance, Wash hands
You are a stakeholder in helping us to maintain our wellness standards. Please personally model and help others about wearing a mask that fully covers nose and mouth, social distancing, and frequent hand sanitization.
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