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Awana/IMPACT Health Screening Form
Please complete this form for each child/student/volunteer that will be attending Awana or IMPACT! this week. If a parent will be staying in the building during the programs, please complete this form for the parent as well.
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Option 1
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Option 1
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Option 1
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Untitled Title
Child/Teen/Parent/Volunteer First & Last Name
*
Your answer
Has the child/adult or a member of their household experienced COVID symptoms (fever, cough, shortness of breath, loss of taste/smell, nausea, etc.) in the last 7 days?
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Yes
No
Other:
Has the child/adult or a member of their household traveled to a COVID "hotspot" or outside of NY/PA in the last 7 days?
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Yes
No
Has the child/adult or a member of their household been asked to quarantine due to possible exposure to COVID in the last 7 days?
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Yes
No
Has the child/adult or a member of their household been tested for COVID in the last 7 days?
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Yes
No
If yes, what was the result of the test? *If the result was positive or you are still awaiting results, please contact Carol Clymer at 570-423-5129 before coming to Awana/IMPACT!
Negative
Positive
Still awaiting results
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