Covid-19 Health Check

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Date *

YYYY

Child's name *

Summer camp *

Is your child experiencing any of the following? (check all that apply) *

Fever higher than 38°C

Chills

Cough

Loss of sense of smell or taste

Difficulty breathing

Sore throat

Loss of appetite

Extreme fatigue or tiredness

Headache

Body aches

Nausea or vomiting

Diarrhea

None of the above

Required

Are any other members of your household experiencing any of the following? (check all that apply) *

Fever higher than 38°C

Chills

Cough

Loss of sense of smell or taste

Difficulty breathing

Sore throat

Loss of appetite

Extreme fatigue or tiredness

Headache

Body aches

Nausea or vomiting

Diarrhea

None of the above

Required

Has anyone in your household returned from travel outside Canada in the last 14 days? *

Yes

Is anyone in your household a confirmed close contact of a person confirmed to have COVID-19? (You will know if this is the case, as you will have been contacted by Public Health.) *

Yes

The viability of keeping the Lyceum open is dependent on the cooperation and diligence of our community members. For the duration of your child's summer camp, we are counting on you to immediately report any changes to the answers given above. *

I confirm the answers to the above questions to be true

Required

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