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Day Camp Camper Health Screening Form

Checks a camper's health status, travel history, and vaccination record before they join day camp activities.

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Name

First Name

Last Name

Date of Birth

Gender

Male Female Other

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

School Name

Grade Level

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone

Parent/Guardian Email

Emergency Contact Person

First Name

Last Name

Emergency Contact Person Phone

Is your child experiencing any COVID-19 symptoms within 48 hours? Please select all the symptoms below (If none, please leave this field blank):

Fever Cough Shortness of breath Sore throat Loss of taste or smell

Did the camper have any travel history within the last 7-14 days?

Yes No

Is it out of state travel or international travel?

Out of state International Both

Was the camper had been in close contact or proximity to someone who's been tested for COVID-19 within the last 14 days?

Yes No

Is the camper currently living in the same household to someone who is positive for COVID-19?

Yes No

Has the child been vaccinated for COVID-19?

Yes No

What is the vaccination date?

Is it for first dose or second dose?

First dose Second dose

Authorized Person Signature

Sign here

Date Signed

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