LLDC Online Health Screening Form
Date
-
Month
-
Day
Year
Date
Who is filling out this form?
First Name
Last Name
Camper/Staff Name
*
First Name
Last Name
Best Phone Number
-
Area Code
Phone Number
Email
example@example.com
Are you planning on coming to Camp today?
YES
NO
Not Sure
Do you have any of the following symptoms?:
*
Temperature/fever of 100.4 degrees or higher (must be fever-free for 24 hours to return to camp)
Sore throat
New and persistent cough
Shortness of breath or any difficulty breathing
Diarrhea or vomiting
New onset of severe headache
New loss of taste or smell
No Symptoms
Have you been in contact with anyone recently who is experiencing these symptoms?
*
Yes
No
Have you been in contact with anyone recently who has since tested positive for Covid-19?
*
Yes
No
Not Sure
Anything else we should know? (this information will remain confidential)
Submit
Should be Empty: