Health Screening

Health Screening Questionnaire

Thank you for taking the time to answer these questions. The following questions are to inform our staff team about your child(ren)'s health today. If you have more than one child registered for program, you can now include multiple children's names on this form. Please note that the date and time is automatically recorded when completing this questionnaire.
Today's Date

Month Day Year
Date
Time

: Hour Minutes AM/PM Option
Where is your child(ren) registered for programs? *

Boys and Girls Club of London A.S.P. Pond Mills
Child's Name

First Name Last Name
Child(ren)'s Name(s): Please include their first and last names for all the children attending. *
Which location is your child registered for camp?

Boys and Girls Club of London Kidscape Indoor Playground
1. Do you, your child(ren), or any member of your household have any of the following symptoms:
a) Fever? *

NO YES
b) Difficulty Breathing? *

NO YES
c) Cough, sore throat or difficulty swallowing? *

NO YES
d) Hoarse voice? *

NO YES
e) Changes in sense of taste or smell *

NO YES
f) Runny nose, sneezing or nasal congestion? *

NO YES
g) Nausea/vomiting, diarrhea or abdominal pain? *

NO YES
h) Chills? *

NO YES
i) Unexplained fatigue (tiredness)? *

NO YES
j) New or unusual muscle aches? *

NO YES
k) Conjunctivitis (Pink eye)? *

NO YES
2. Have you, your child(ren), or any member of your household travelled outside of Canada within the last 14 days? *

NO YES
3. Have you, your child(ren), or any member of your household had close contact without consistent and appropriate use of personal protective equipment, with a confirmed or probable COVID-19 case within the last 14 days? *

NO YES
4. Have you, your child(ren) or any member of your household had close contact without consistent and appropriate use of personal protective equipment with a person with acute respiratory illness in the last 14 days? *

NO YES
Thank you for your responses. This form will be submitted to our Health Screening Staff at the {whereIs}.

They will be taking your child(ren)'s temperature with an infrared (contactless) thermometer upon entry, and recording the temperature on this Health Questionnaire.

Thank you very much for your patience and understanding!
Should be Empty:

Health Screening Questionnaire