COVID-19 Symptom Monitoring Form
Please fill out this survey each day morning bringing your child to our program.
Child(ren)'s First and Last Name
First and Last Name of person filling out this form
Are you, your child(ren), and/or anyone in your household currently experiencing any of the following symptoms?
Fever (>100) or Feverish
Rapid breathing or difficulty breathing (without recent physical activity)
Gastrointestinal symptoms (diarrhea, nausea, vomiting)
New loss of taste/smell
New muscle aches
Any other sign of illness
None of the Above
To the best of your knowledge, have you, your child(ren), or anyone else in your household been in direct contact with anyone who has been exposed to COVID-19 in the past 14 days?
To the best of your knowledge, have you, your child(ren), and everyone else in your household been following social-distancing guidelines and wearing face coverings in public for the past 14 days?
Best Phone Number to reach Parent/Guardian today
By checking this box, I affirm that all the of the information entered on this form is accurate and release Cambridge Community Center from any and all liability for unintentional exposure or harm due to COVID-19.
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This form was created inside of Cambridge Community Center, Inc..