Youth Group Covid-19 Health Screening Form
Full Name
Date
Parent/Guardian Name
Contact Number
Email Address
Symptoms Check (In the last 24 hours, have you experienced any of the following?)
Fever or chills
Cough
Shortness of breath or difficulty breathing
Sore throat
Loss of taste or smell
Muscle or body aches
Other symptoms
In the past 10 days, have you:
Tested positive for Covid-19?
Yes
No
Been in close contact with anyone diagnosed with Covid-19?
Yes
No
Traveled outside the country or to a high-risk area?
Yes
No
Signature
Youth/Parent/Guardian Signature
Signature Date