Into the Woods Alaska Daily Health Questionnaire (DHQ)

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Child(rens) Name(s) *

Parent/Legal Guardian Name *

Please click "yes" or "no" to the questions below: *

yes

Have you, anyone in your house, or your child returned from traveling outside the state of Alaska within the last 14 days?

Have you anyone in your house, or your child had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

Have you anyone in your house, or your child been in close contact with anyone who has traveled within the last 14 days?

Have you anyone in your house, experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)?

yes

Have you, anyone in your house, or your child returned from traveling outside the state of Alaska within the last 14 days?

Have you anyone in your house, or your child had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

Have you anyone in your house, or your child been in close contact with anyone who has traveled within the last 14 days?

Have you anyone in your house, experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)?

Look for emergency warning signs for COVID-19. If someone is showing any of these signs, seek emergency medical care immediately: Trouble breathing, Persistent pain or pressure in the chest, New confusion. Inability to wake or stay awake, Bluish lips or face. Call your medical provider for any other symptoms that are severe or concerning to you. *

I understand.

If the answer is “yes” to any of the questions above, unfortunately we cannot let your child take part in our camp until 10 days after the last sign of symptoms. We are sorry for any inconvenience and thank you for your understanding and patience. *

I understand

Required

I have read and agree to the ITWAK Covid-19 Mitigation Plan. I understand that attending in person programs is at my own risk and release ITWAK from any responsibility. Additionally, I will take precautions as stated in the Mitigation Plan and refrain from attending ANY PROGRAM if I develop symptoms or come in contact with someone showing symptoms. *

I agree

Required

Electronic Signature, Parent/Legal Guardian *

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