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COVID-19 Symptom Monitoring Form
Please fill out this survey each day morning bringing your child to our program.
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* Indicates required question
Child's Name:
*
Your answer
Parent/Guardian
*
Your answer
Are you, your child(ren), and/or anyone in your household currently experiencing any of the following symptoms?
*
Fever (>100) or Feverish
Cough
Sore Throat
Rapid breathing or difficulty breathing (without recent physical activity)
Gastrointestinal symptoms (diarrhea, nausea, vomiting)
Fatigue
Headache
New loss of taste/smell
New muscle aches
Any other sign of illness
None of the Above
Required
To the best of your knowledge, have you, your child(ren), or anyone else in your household been in direct contact with anyone who has been exposed to COVID-19 in the past 14 days?
*
Yes
No
To the best of your knowledge, have you, your child(ren), and everyone else in your household been following social-distancing guidelines and wearing face coverings in public for the past 14 days?
*
Yes
No
Best Phone Number to reach Parent/Guardian today
*
Your answer
Confirmation
*
By checking this box, I affirm that all the of the information entered on this form is accurate and release Cambridge Community Center from any and all liability for unintentional exposure or harm due to COVID-19.
Required
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