Daily Health Screening- Agoura 2021

STAFF 2021 Daily Health Screening Form: The Agoura Hills Art Camp

CAMPERS DO NOT NEED TO FILL THIS IN!

Campers will participate in a VERBAL screening at Drop Off.

This is JUST for STAFF. Thanks!

Each STAFF MEMBER must complete and submit this form each day before arriving to campus.

Please fill in your OWN name where it says CAMPER NAME, Thank you!

If you are over 18, fill in your OWN name where it says PARENT'S NAME

If you are under 18, fill in your PARENT'S NAME where it says PARENT'S NAME

If the answer to any of the following questiions is YES, you must STAY HOME.

First Name: *

Last Name *

Camper's Group Number (or if you are a Staff Member please select "I am a Staff Member") *

Email Address *

Parents, has your child had contact with a person known to be infected with or suspected to have Coronavirus Disease 2019 (COVID19) within the last 10 days? Staff, have you had contact with a person known to be infected with or suspected to have Coronavirus Disease 2019 (COVID19) within the last 10 days? *

Yes

No

Has your child traveled outside of the state of California in the past 7 days? *

Yes

No

Has your child experienced any of the following syptoms in the past 24 hours?

In the last 48 hours, has/have your child(ren) experienced any of the following symptoms:

Fever (over 100F)
Headache
Cough
Sore Throat
Muscle Aches/Chills
Shortness of Breath
Gastrointestional (Nausea, Vomiting, Diarrhea) *

First Name (If you are UNDER 18, please put your PARENT'S NAME here)! *

Signature *

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