Volunteer Temperature Screening Form

VOLUNTEER TEMPERATURE SCREENING FORM
This form is to be completed 24 hours prior to coming in to volunteer. If not completed, you will be asked to reschedule your volunteer date.
FULL NAME
DATE OF BIRTH

Month Day Year
Date
AGE
EMERGENCY CONTACT
RELATIONSHIP
PHONE NUMBER
DAILY TEMPERATURE CHECK

DAY ONE

DAY TWO

DAY THREE

DAY FOUR

DAY FIVE

DAY SIX

DAY SEVEN

Temperature

I/My Child have been fever free for the past seven days.
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SYMPTOMS IN THE LAST TWO WEEKS -- Check any that apply

Diarrhea Body Aches Persistent Headache Sore Throat Fever Cough Chills Vomiting Change in Taste or Smell Change in appetite Generally not feeling well
If any of the above apply to you, we ask that you wait until you are symptom free before volunteering.

I/My Child have been symptom free for the past 14 days.
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Pre-Existing Illnesses
Individuals with pre-existing conditions such as cardiovascular disease, respiratory disease including asthma, diabetes, and immunocompromised are at an increased risk

of severe illness if COVID-19 is contracted.
If you have any pre-existing illnesses, please list them here
I understand the implied risk of pre-existing illnesses
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Contact History -- Check any that apply
I have been diagnosed with COVID-19. I have a close contact that has been in contact with someone exposed to or infected with COVID-19 in the last 14 days. I have a household member currently on a watch list for COVID-19 exposure.
If any of the above apply, you may not volunteer at this time.

I verify that I have answered all questions truthfully.
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The health and safety of our staff, guests, and volunteers are our #1 priority. In light of the COVID-19 pandemic, we think it is important that you understand our efforts to manage your health and safety so that you can make an informed choice. We are focused on taking reasonable measures to prevent the spread of COVID-19 on our campus.

The situation continues to change daily, and as such, we will adapt and adjust our protocols and procedures accordingly as we continue to follow federal, state, and local guidelines in efforts to help keep everyone safe.

Ultimately, the choice for you or your child to volunteer is a personal decision. If you are uncomfortable with the risks of COVID-19 by being on our campus, we encourage you to support our mission by sharing social media posts and/or supplying in-kind or monetary
I have read and understand the implications and risks of COVID-19 and consent myself and/or my child to volunteer.
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(If over the age of 18) Signature:

Clear
(If under the age of 18) Parent/Legal Guardian Signature

Clear
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Should be Empty:

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VOLUNTEER TEMPERATURE SCREENING FORM

DAILY TEMPERATURE CHECK

Pre-Existing Illnesses

Contact History -- Check any that apply