Daily Health Screening
Please complete this questionnaire every morning before you bring your child to Summer Camp. If you are dropping off siblings, please complete one form per child. Thank you.

If you answer “Yes” to any of the screening questions, your child should not attend the program, except as otherwise indicated.

Sign in to Google to save your progress. Learn more
Email *
Is your child's temperature higher than or equal to 100.4 degrees Fahrenheit? *
Has your child tested positive for COVID-19 through a diagnostic test within the past 10 days? *
If yes, please list the date of the child's first positive test.
MM
/
DD
/
YYYY
Definition of 'Close Contact'
Being within 6 feet of an individual for 10 minutes or more within a 24-hour period, starting from 2 days before the onset of symptoms -- OR, if asymptomatic, 2 days before the date the positive sample was collected.  
PLEASE NOTE ** Children who experienced 'close contact' as defined above but are asymptomatic may attend a childcare program if they are fully vaccinated OR if they have recovered from laboratory confirmed COVID-19 in the previous 3 months and have not been placed on quarantine.
In the past 10 days, has your child had any known close contact with a person confirmed  positive (by diagnostic test) or suspected (based on symptoms) to have COVID-19?   *
Is your child currently experiencing -- or has your child recently experienced (within the past 10 days) -- ANY of the COVID-19 symptoms listed below?  Please select all that apply. *
Required
Attestation by Parent/Guardian ** I agree that I will monitor my child's symptoms each day, report the outcome to the childcare program, and that I will not bring my child to the program if any of the above symptoms or conditions are present. Please enter your name below. *
Child Name *
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
Google Forms