PGC Youth - Weekly Registration/ COVID-19 Screening

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

As school begins again, to ensure safety for all attendees of PGC Youth events, if you or your child intends to attend PGC events, please fill out this registration and COVID-19 screening WEEKLY. If you do not remember whether you have filled the form for the upcoming week, please complete it.

Please fill the form out for yourself and your own child(ren).
To ensure safety measures, if this form is not filled you or your child will not be able to participate in our activities.

Email *

Name of parent/guardian filling form *

Date attending *

YYYY

Name of attendee #1 *

Name of attendee #2

Name of attendee #3

Name of attendee #4

Symptom List

* A fever (temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher) and/or shakes/chills

* A cough or barking cough (croup) that is NEW or WORSENING? (Not related to asthma, post-infectious reactive airways, COPD, or other known or causes or conditions you already have?)

* NEW or WORSENING shortness of breath? (Not related to asthma or other known causes or conditions that you already have.)

* NEW or WORSENING sore throat? (Not related to seasonal allergies, acid reflux, or other known causes or conditions that you already have?)

* NEW or WORSENING difficulty swallowing? (Painful swallowing not related to other known causes or conditions that you already have.)

* NEW or WORSENING decrease or loss of sense of smell or taste? (Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have.)

* NEW or WORSENING conjunctivitis (pink eye)? (Conjunctivitis not relating to reoccuring styes or other known causes or conditions that you already have.)

* NEW or WORSENING runny or stuffy/congested nose? (Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have.)

** NEW or WORSENING headache? (Unusual, long lasting (not related to tension-type headaches, chronic migraines or other known causes or conditions you already have. *** If you have received a COVID-19 vaccination in the last 48 hours and are experiencing a mild headache that began only after vaccination refer to the note in the next question.)

* NEW or WORSENING digestive issues like nausea, vomiting, diarrhea, stomach pain? (Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have.)

** NEW or WORSENING muscle aches / joint pain? (Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have). *** If you have received a COVID-19 vaccination in the previous 48 hours and are experiencing mild muscle aches/joint pain that only began after vaccination, refer to the note in the next question.)

** NEW or WORSENING fatigue? (Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have). *** If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, refer to the note in the next question.)

* For Older Adults - NEW or WORSENING frequent falls? (applies to older adults having unexplained falls of a greater frequency than normal.)

Does the attendee(s) have COVID-19 symptoms from the list above? *

Yes

In the last 14 days, has the attendee(s) been identified as a "close contact" of someone who currently has COVID-19? *

Yes

Is anyone the attendee(s) live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

Yes

If "Yes" to any of the above. Please DO NOT attend this week and take appropriate measures to ensure you are better before attending. Please feel free to let us know directly so we could pray and care for you and your family!

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