Volunteer Health Screening

Name *

First

Last

I am filling this form out for our whole family and all answers represent the names below

Names of people in my family

Date *

Instructions

ALL VOLUNTEERS must be asked the following below, within 24 hours of coming to camp. This record will be kept for 14 days from completion of this form and this form is available upon request from the Public Health Department.

1 - Do you have any of the following respiratory symptoms which are new or unusual for you? *

Fever
New or worsening cough
New or worsening shortness of breath
None of the above

If YES to any, you will not be allowed to come to Camp Chinquapin at this time. - If NO to all, proceed to remaining questions

2 - Volunteer's Temperature *

3 - Do you have a fever (temperature 100.4°F or greater) *

If YES, you will not be allowed to come to Camp Chinquapin at this time. - If NO, proceed to question 4.

4 - 1 - Are you feeling feverish? *

4 - 2 - Are you having chills? *

If YES to any, you will not be allowed to come to Camp Chinquapin at this time. If NO, proceed to question 5.

5 - In the last 14 days have you been exposed to any persons with confirmed COVID-19 by lab test? *

If YES, you will not be allowed to come to Camp Chinquapin at this time. If NO, we look forward to seeing you soon.

Person performing screening *

Relationship to Volunteer being screened

If you are doing this screening for someone other than yourself, please note above

Comment

address

201 Dodge Ridge Road

Pinecrest

CA 95364

Camp Chinquapin a ministry of CrossPoint Community Church. Operating under a special use permit from Stanislaus National Forest.

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