Day Camp Camper Health Screening Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
School Name
Grade Level
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Emergency Contact Person
First Name
Last Name
Emergency Contact Person Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Is your child experiencing any COVID-19 symptoms within 48 hours? Please select all the symptoms below (If none, please leave this field blank):
Temperature (100.4°F or higher)
Nasal congestion
Runny nose
Loss of taste
Loss of smell
Difficulty of breathing
Cough
Sore throat
Headache
Body weakness
Diarrhea
Did the camper have any travel history within the last 7-14
Yes
No
Is it out of state travel or international travel?
Out of state
International
Was the camper had been in close contact or proximity to someone who's been tested for COVID-19 within the last 14 days?
Yes
No
Is the camper currently living in the same household to someone who is positive for COVID-19?
Yes
No
Has the child been vaccinated for COVID-19?
Yes
No
What is the vaccination date?
-
Month
-
Day
Year
Date
Is it for first dose or second dose?
First dose
Second dose
Authorized Person Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: