COVID-19 Pre-Arrival Health Screening and Test Verification for Mountain Friends Camp 2022
All participants (campers, CITs, staff and volunteers) must complete and submit this form approximately 24 hours before your arrival at camp. Parent/guardian should monitor symptoms and complete on behalf of camper/CIT. If a participant answers "YES" to any of the below questions, they are not permitted to participate in Mountain Friends Camp without additional clearance and permission from the director. Please notify director Anastacia Ebi (435-554-1132/ firstname.lastname@example.org) if you have responded "YES" to any question, or if anything changes before your arrival. Thank you for helping to keep our community healthy and safe for everyone!
First and Last name
Parent/ Emergency Contact Name
First and Last name
Phone Number (staff participant, OR camper parent)
E-mail Address (staff participant, or camper parent)
COVID-19 SYMPTOM and EXPOSURE CHECKLIST
1. Has the participant experienced any of the below symptoms in the past 14 days?
Fever (greater than 99 F)?
Shortness of breath/difficulty breathing?
Loss of taste or smell?
2. Has anyone in your household experienced any of the above symptoms in the last 14 days?
3. Has anyone in your household tested positive for Covid-19 in the last 14 days?
4. Has participant been around anyone with confirmed or suspected COVID-19 for more than 15 minutes, in the past 14 days?
5. Are any of the symptoms above new and/or unexplained by prior health conditions?
What prior health conditions are present that potentially explain symptoms?
Enter NA if no relevant health conditions
Please fully explain any and all "Yes" answers above
COVID-19 Test Results Pre-Arrival
Please upload verification/image of your COVID-19 test taken prior to arrival at camp. PCR tests should be taken 48 hours prior to arrival. Rapid Antigen test should be taken 24 hours prior to arrival. We also require a rapid antigen test at time of arrival to be taken in presence of camp staff, if possible please bring a second test with you for arrival.
Upload test result/image here
Write name, date and time taken on test/paper and include in file, or share results from lab test with name and date
Participant (or responsible adult for minor children) signature indicates that I monitored for symptoms daily for 14 days prior to camp and to the best of my ability. I understand that arriving to camp healthy is vital to a healthy camp for all campers and staff, but that we cannot rule out the possibility of infectious disease in a group living environment.
Should be Empty: