COVID CHECKUP for Troop 41
Completion of this form is required for ANYONE attending Troop 41 indoor gatherings or activities as long as COVID-19 continues to be a widespread health care issue.

This form is to be completed by adult participants and by parents for participants under 18.

This form must be completed and submitted on the day of the event.

If the answer is "YES" to any of the following symptoms or conditions, the Boy Scouts of America requires that the participant MUST NOT attend in-person scouting events until medically cleared by their health care provider.

Also required:
*  Wear a snug fitting mask.
*  Keep 6-foot minimum social distancing.
*  Practice strict hygiene and disinfection.
*  Bring your own chair.

If the participant named herein develops any of the symptoms or conditions listed below, adult participants and parents of participants under 18 MUST communicate with Troop 41 leadership any COVID-19 results in a timely fashion: Jim Fox, Scoutmaster (foxers138@yahoo.com) and Randy Carlson, Committee Chairman (isurac94@gmail.com).

For reference, see BSA COVID-19 and Medical Safety Checklists:
https://filestore.scouting.org/filestore/HealthSafety/pdf/680-693.pdf
https://filestore.scouting.org/filestore/HealthSafety/pdf/680-057.pdf

Troop 41 thanks you for your time, understanding, and compliance.
TODAY'S DATE = DATE OF EVENT *
PARTICIPANT'S FULL NAME *
SYMPTOM'S AND CONDITIONS *
ALL answers must be marked "NO" to attend.
YES
NO
Temperature 100.4 F or higher
Sore throat
New uncontrolled cough that causes difficulty breathing
Diarrhea, vomiting, or abdominal pain
New onset of severe headache, especially with fever
Shortness of breath or difficulty breathing
Chills
Repeated shaking with chills
Muscle pain
Loss of taste or smell
Flu-like symptoms
Have household member who is suspected of having COVID-19
Had close contact with a person with confirmed COVID-19 within 6 feet for at least 15 minutes
Been in close contact with anyone who has traveled on a cruise ship, internationally, or to an area with a known communicable disease outbreak in the last 14 days
ASSUMPTION OF RISK *
Required
CONTACT TRACING *
Required
RELEASE AND WAIVER *
Required
ELECTRONIC SIGNATURE (Adult Participant or Parent of Participants under 18) *
Type your NAME as your signature below.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy