Family Camp Pre Screening – Camp Chinquapin

Name of Family *

Last Name

COVID-19 Pre-Screening

Please read and respond honestly to each question

In the last 14 days has anyone in your family been exposed to any persons with confirmed COVID-19 by lab test or been in contact with anyone exhibiting COVID-19 symptoms? *

YES
NO

In the last 14 days has anyone in your household been sick or been around anyone that has been sick? *

YES
NO

In the last 14 days has anyone in your family had any of the symptoms listed below? *

YES
NO

●Fever or chills ●Cough ●Shortness of breath or difficulty breathing ●Fatigue ●Muscle or body aches ●Headache ●New loss of taste or smell ●Sore throat ●Congestion or runny nose ●Nausea or vomiting ●Diarrhea

Does anyone in your family have a temperature above 100.4° *

YES
NO

Date

Family Camp Pre-Screening

COVID-19 Pre-Screening

address