Daily Participant Screening Form QCMC 2020

QCMC Daily Participant Screening Form

 

In the past 24 hours, has your child experienced the following cold, flu or COVID-19 like symptoms:

 

Sore throat: YES [   ] NO [   ]
Cough: YES [   ] NO [   ]
Shortness of breath or difficulty breathing: YES [   ] NO [   ]
Stuffy or runny nose: YES [   ] NO [   ]
Loss of smell: YES [   ] NO [   ]
Fever or chills: YES [   ] NO [   ]

 

If you answered YES to any symptoms above, your child will not be permitted to attend camp.

Please self-isolate at home, and contact your doctor or primary care provider for further instructions.

 

If you answered NO to all of the above, please complete the next part of the form:

 

In the past 14 days, has your child:

Travelled to any countries outside of Canada (including the United States): YES [   ] NO [   ]
Had close contact with a person diagnosed with COVID-19: YES [   ] NO [   ]
Had close contact with a person under investigation for COVID-19: YES [   ] NO [   ]
Been instructed to self isolate by a doctor, nurse or public health official: YES [   ] NO [   ]

 

If you answered YES to any of the above, your child will not be permitted to attend camp until cleared by a public health official.

If you have answered NO to all of the above, have a great day at camp!

 

I have answered above with regards to my child’s health at the beginning of the day, prior to their arrival at camp.

 

Participant’s Name: _______________________________             Date: __________________

 

Parent’s Signature: ______________________________