Where the Wild Things Grow - Westside Location
COVID-19 Daily Health Screening Form
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Full Name of Attending Child *
Current Temperature *
Essential visitors must fill out this questionnaire to decide if you should enter today. Please check the boxes if you or your attending child has ANY of the following symptoms.  (these include fever, cough, breathing difficulties, sore throat, chills, painful swallowing, runny nose/nasal congestion, feeling unwell/fatigued, nausea/vomiting/diarrhea, loss of appetite, loss of sense of taste or smell, muscle/joint aches, headache, and conjunctivitis) *
Required
Has your child travelled outside of Canada in the last 14 days or has someone in the household travelled outside of Canada in the last 14 days and is ill? *
Have you or your children attending the program had close unprotected* contact (face-to-face contact within 2 meters/6 feet) with someone who is ill with cough and/or fever?*unprotected means close contact without personal protection equipment (PPE) *
Have you or your children attending the program had close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19? *
If you clicked any of the symptom boxes above or answered "YES" to the questions, please DO NOT enter at this time. If you exhibit no symptoms and answered "NO" to the questions, please sign in and out, and practice hand hygiene (washing hands for 30 seconds and/or use of hand sanitizer) before and after your visit. Our goal is to minimize the risk of infection to our staff and children.  Thank you for your understanding and cooperation.
Full Name of Parent Filling Out Form *
Clicking this box serves as a legal signature and certifies the above information is accurate. *
Required
Date of Form Submission *
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