Pre-Camp Health Screening Form

Kindly complete this form on a daily basis for 14 days before the Summer Camp that will start on April 20, 2021. This means that you need to start completing this form on April 6, 2021.

This will help you and us monitor the health condition of the camper.

Thank you for your cooperation.

Select the date you have taken the temperature and assess the camper

What is the current temperature of the camper?

Please display in °F

Camper Name

First NameLast Name

Age

Gender

Date of Birth

Date

Parent/Guardian Name

First NameLast Name

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

YesNo

Does the camper have any allergies? If yes, please list them below.

I understand that there is a risk of being infected with COVID-19 during the camp.

I understand that there is a risk of exposure for COVID-19.

I confirm that being exposed or infected might lead to illness, injury, disability, or death.

I released the camp facility and the organizer from any liabilities that might happen during the camp.

By signing below, you read the statement above and you confirm that all information in this form is accurate and true.

Signature

Date Signed

Date

Pre-Camp Health Screening Form

RELEASE