Winter Wonderland - Daily Health Screening

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this form before 8:00am each day of program. We are taking these proactive steps to ensure everyone's health and safety. Please answer all of the questions. If your child is not attending a day or if you have any questions please call North Reading Parks & Recreation at 978-664-6016.

Anyone who answers "YES" or has symptoms to any of these questions cannot participate that day.

Email *

Participant First Name *

Participant Last Name *

Today or in the past 24 hours, has the participant or any household members had any of the following symptoms? *

Fever (temperature of 100.4°F or above), felt feverish, or had chills?

Cough?

Sore throat?

Difficulty breathing?

Gastrointestinal symptoms (diarrhea, nausea, vomiting)?

Unexplained Fatigue?

Headache?

New loss of smell/taste?

New muscle aches?

Any other signs of illness?

No symptoms.

In the past 10 days, has the participant had close contact with a person known to be infected with the novel coronavirus (COVID-19)? *

Yes

I as parent/caregiver am reporting all responses of the participant accurately. I understand that if any of the above answers are yes, my child will not be allowed to participate that day and therefore must stay/return home with their parent or caregiver. *

I agree

Parent/caregiver name filling out form. *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms