COVID-19 Questionairre

ALL FAMILIES MUST BE ASKED DAILY.

Date *

Date

Member's Name: *

Member's Name:

1. In the last 10 days, has your child/children been within 6 feet (unprotected) of anyone with a positive COVID-19 or Coronavirus diagnosis? *

YES

NO

2. Does your child/children or anyone in close contact with your child/children have a fever or temperature over 100.0f or greater? *

YES

NO

3. Does your child/children or anyone in close contact with your child/children have other symptoms of a lower respiratory condition? (sore throat, cough, shortness of breath?) *

YES

NO

4. Has your child returned from travel abroad in the last 14 days? *

YES

NO

5. Has your child been on a cruise or in another setting with confined crowds in the last 14 days? *

YES

NO

IF ANSWERED "YES" TO ANY OF THESE QUESTIONS, YOUR CHILD WILL NOT BE ABLE TO ATTEND THE CLUB TODAY.

PARENT MUST SIGN THEIR NAME BELOW: *

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