Troop 66 Covid-19 Pre-Activity Screening
Patrol *
First Name *
Last Name *
In the past 48 hours, have you had one of the following symptoms unrelated to a pre-existing medical condition: frequent cough or shortness of breath, sore throat, chills, headache, muscle pain, new loss of taste or smell? *
What is your temperature today? *
Within the past 10 days, have you been in close physical contact (6 feet or closer for at least 10 minutes), with a person that is known to have laboratory-confirmed Covid-19 or with anyone that has symptoms consistent with Covid-19? *
Within the last 10 days, have you travelled to one of the states on the "Travel Advisory List" established by the Governor's Office? *
If you have answered yes to any of the above questions, do not attend the activity and contact your patrol leader.
I attest that all information contained herein to be accurate to the best of my knowledge. In doing so, you agree your electronic signature is the legal equivalent of your manual signature on this screening. *
Enter Full Name of Particpipant if adult or Parent/Guardian authorizing for a minor
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