COVID-19 Girls Group Screening
Please answer the following questions to help us decide if you should or should not go to girls' group today.

PLEASE STAY HOME if you are not feeling 100% or until everyone with symptoms gets a negative COVID-19 test result, or is cleared by public health, or is diagnosed with another illness.

This screening cannot diagnose you. If you have medical questions, consult a health care provider or your local public health unit.  Listen to the advice of your local public health unit first, as their advice overrules the advice in this screening. Information will only be for tracking purposed for Power4Teens Inc and will not be shared with anyone.

You MUST screen for COVID-19 BEFORE going to Power4Teens girl group EACH WEEK.
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Email *
For weekly tracking, please select today’s date: *
Please complete this form the day of girls group, not in advance as symptoms can change
Name of Parent/Guardian: *
Name of attendee (daughters name): *
1. I am taking this screening as a: *
Is your household (all parties) currently experiencing any of these symptoms? *
Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.
In the last 10 days, has your household tested positive on a rapid antigen test or home-based self-testing kit? *
In the last 10 days, have you or anyone your household been identified as a “close contact” of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)? *
If public health has advised you that you do not need to self-isolate, select “No.”
I agree to the following: 1. I understand that POWER4TEENS INC. cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client. 2. Our business is following all necessary procedures to prevent the spread of COVID-19. By agreeing below, I agree to each statement above and release POWER4TEENS INC. from any and all liability for unintentional exposure or harm due to COVID-19. *
A copy of your responses will be emailed to the address you provided.
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