RSBC Covid-19 Daily Screening
Daily Camp Participation Form
Email address *
Today's Date *
Who is filling out this form? *
Camper Name (First Name/Last Name) *
Camper Age *
Have you been designated by the Department of Health as a close contact of a person who tested positive for Covid-19 within the last 14 days? *
In the last 14 days, have you traveled to a high-risk Covid-19 location either internationally or to any state or territory on the NYS Travel Advisory List? *
Was your temperature above 100 degrees (F) this morning? *
Symptoms: Do you currently have (or have had in the last 10 days) one or more of these new or worsening symptoms? * A temperature greater than equal to 100 degrees F (37.8 C) * Feel feverish or have chills * Cough * Loss of taste or smell * Fatigue/feeling of tiredness * Sore throat * Shortness of breath or trouble breathing * Nausea, vomiting, diarrhea * Muscle pain or body aches * Headaches * Nasal congestion/runny nose AND have not been cleared by a medical practioner *
Is there currently anyone in your home that is undergoing an evaluation for Covid-19 or has a fever greater than 100 degrees F (37.8 degrees C), significant cough, shortness of breath, or loss of taste or smell? *
If the answer to any of these questions on this screening is "yes", please contact a camp administrator before bringing your child to camp. *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy