GTCYS Concertino West Health Screening Form

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Parents/guardians need to complete this form for their child in advance of every GTCYS activity to determine eligibility to attend. Students will not be admitted to the activity if this screening step is not submitted in advance. Thank you.

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Student First Name *

Student Last Name *

Valid email for your family *

Orchestra Cohort *

Health Screening Questions

Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with their mucus or saliva, in the past 14 days?

In the last 48 hours, have you had any of the following NEW symptoms?

--Fever of 100 F (37.8 C) or above, or possible fever symptoms like alternating chills and sweating
--Cough
--Trouble breathing, shortness of breath or severe wheezing
--Chills or repeated shaking with chills
--Muscle aches
--Sore throat
--Loss of smell or taste, or a change in taste
--Nausea, vomiting or diarrhea
--Headache

If you can answer yes to ANY of the above, select Yes. If none of the above apply, select No *

Yes

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