Glendora Unified School District- Cross Country
Active Screening Cross Country Check-in

This form is designed to identify possible symptoms of COVID-19 and/or other potentially contagious illnesses.

By submitting this form you are attesting that the following information is true and that to your knowledge you are not experiencing any signs of potentially contagious illness. Please note that you should not enter a school campus if you have any symptoms or feel ill.

This form has been adapted from the LA County Department of Public Health's COVID-19 Reopening protocols. This form does not constitute medical advice and is for screening purposes only.
First Name *
Last Name *
Do you currently have any symptoms of fever, cough, shortness of breath, chills, muscle pain, sore throat, or sudden loss of taste/smell? *
In the last 14 days, has anyone in your household(s) experienced any of the above symptoms? *
In the last 14 days, have you or anyone in your household had contact with a confirmed or suspected case of COVID-19? *
Do you have a fever above 100.4 degrees? *
What is your arrival temperature? *
Time entering campus *
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