Guest Pre-Screening

Please submit no earlier than 48 hours before you arrive

Please fill out all information on form – This form will be submitted to Camp Chinquapin

You will be contacted by your group leader if you can’t come to camp at this time

Name of person filling out the form *

First

Last

I am filling this out for someone else *

COVID-19 Pre-Screening

Please read and respond honestly to each question

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

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

In the last 14 days have you had any of the symptoms listed below? *

●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

Guest Temperature *

Date

Guest Pre-Screening

Please submit no earlier than 48 hours before you arrive

COVID-19 Pre-Screening

address