Social Club Health Screening Form
Rules and Regulations:
Activities will be cut-off in a half in terms of duration to observe social gathering rules.
Club apparel and equipment will be separated at an acceptable distance.
There will be a limit on the number of allowed guests.
The temperature will be taken upon entry.
COVID-19 related questions will be asked upon entry.
Wear a proper PPE like a face mask and face shield.
Observe physical and social distancing.
Name
First Name
Last Name
Grade Level
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current Body Temperature
Do you have any of the following symptoms in the last 14 days? Select all that apply:
Temperature (100.4F or higher)
Nasal congestion
Runny nose
Loss of taste
Loss of smell
Difficulty of breathing
Cough
Sore throat
Headache
Body weakness
Diarrhea
Did you travel outside the city in the last 7 days?
Yes
No
Did you have a close contact to someone who was diagnosed with COVID-19?
Yes
No
Did you have a close contact to someone who had symptoms of COVID-19?
Yes
No
Signature
Date Signed
 -
Month
 -
Day
Year
Date
Submit
Should be Empty: