Covid-19 Questionnaire
Daily Health Screening for your Good Witch Camper.
1. Today's Date
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Month
-
Day
Year
Date
2. Camper's Name
3. Has your child or anyone in your household experienced the loss of taste or smell in the last ten days?
Yes
No
4. Has your child or anyone in your household had a fever greater than 100 degrees F, or symptoms of respiratory illness such as cough, sore throat, difficulty breathing or shortness of breath within the last 24 hours?
Yes
No
5. Has your child or anyone in your household had a confirmed case of COVID-19 or awaiting test results related to a suspected COVID-19 diagnosis within the last 10 days?
Yes
No
6. Has your child or anyone in your household been in close contact with someone who has a confirmed case of COVID-19, or awaiting tests related to a suspected COVID-19 diagnosis within the last 10 days?
Yes
No
Has your child or anyone in your household traveled outside of the state of Massachusetts to a high risk state/country within the last 10 days?
Yes
No
Please list additional information here, including allergies or medical information we should know about.
Signature
Submit
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