Agape B.E.A.T Camp Covid-19 Health Screening Form
This form is to be completed each week in order for campers to be permitted into the camp site.
Campers First and Last Name *
Parent Email *
Parent Phone Number *
1. In the last 10 days has the camper been diagnosed with Covid-19 or had a test confirming she has the virus?
Clear selection
2. In the past 14 days, has the camper had "Close Contact" with someone who has been diagnosed with COVID-19 or had a test confirming they have the virus while they were contagious? *"Close Contact" means you had any of the following types of contact with the person with COVID-19 while they were contagious: ^Lived or stayed overnight with them ^Stayed within 6 feet of them for more than 15 minutes ^Took care of them or they took care of you ^ Exposed to direct contact with their body fluids or secretions (e.g., they coughed or sneezed on you) while you were not wearing a face mask, gown, and gloves.**Contagiousness: People with COVID-19 are considered infectious starting 48 hours before their symptoms began until 1) they haven't had a fever for at least 24 hours, 2) their symptoms have improved, AND 3) at least 10 days have passed since their symptoms have began. If the person with COVID-19 never had symptoms, then they are considered infectious starting 48 hours before their test that confirmed they have COVID-19 until 10 days after the date of the test.
Clear selection
3. Has the camper or someone in their household had one or more of these symptoms today or within the past 24 hours which is new or not explained by another condition? *Fever (100.4F/38C or greater), chills, repeated shaking/shivering *Headache *Cough *Loss of taste or smell *Sore throat *Muscle or body aches*Shortness of breath, difficulty breathing *Runny or congested nose* Feeling unusually weak or fatigued *Nausea or vomiting *
I understand that if I answered "YES" to ANY of these questions, my child is not able to attend camp. If answered YES to QUESTION 1 OR QUESTION 2 in accordance with the Health Department's directive, your child must isolate or quarantine accordingly. If your child is feeling well enough, we can set up camp virtually until her isolation or quarantine is over. If answered YES to QUESTION 3, your child may have COVID-19 and to keep others safe, your child should isolate until you know whether she or someone in her household has COVID-19, you may want to get tested! *
Name of Parent or Guardian (18 or older) completing this form: *
Date Completed *
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