13GEM COVID Screening Form
Review the following questions before each class and STAY HOME if any answer is “YES”.

Symptoms of COVID-19:

-Fever (100.4 F) or chills
-Cough
-Shortness of breath or difficulty breathing
-Recent loss of taste or smell
-Unusual fatigue
-Muscle or body aches
-Headache
-Sore throat
-Congestion or runny nose
-Nausea or vomiting
-Diarrhea

***NOTE: For families with multiple students enrolled, please complete an individual form for each sibling***
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Has your student had any of the SYMPTOMS OF COVID-19 listed above within the past 24 hours that are not caused by another condition? For those returning from a Summer break vacation, have you had any of the above symptoms in the past 3 days? *
Has your student been in close contact with anyone with a confirmed case of COVID-19 within the past 14 days? Close contact means being within 6 feet (2 meters) of an infected person for 15 minutes or more. *
Has your student had a positive COVID-19 test for the active virus in the past 10 days? *
Within the past 14 days, has a public health or medical professional told you to monitor, isolate, or quarantine your student because of concerns about COVID-19? *
Date *
MM
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DD
/
YYYY
Student First Name *
Student Last Name *
Parent email *
Camp Attended *
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