COVID Pre-activity Screening Form

 

ENVIRONMENTAL LEARNING CENTER - LAGOON ISLAND ADVENTURE CAMP

COVID-19 Pre-Activity Screening Form

The Environmental Learning Center’s main priority and concern is the health and safety of our community, and our staff and volunteers. To help keep your family and our staff and volunteers safe, we require that you complete this screening form within 24 hours prior to the start of your child’s camp session. Please print and complete this form and bring it with you to the activity. One form per family must be completed by a legal parent or guardian with whom the child is residing. If you have children signed up for different weeks of camp, this form must be completed prior to the start of each camp. We strongly encourage families with more than one child to register all children for the same camp session.

 

CAMPER NAME: ____________________________________________________

 

CAMPER NAME: ____________________________________________________

 

CAMPER NAME: ____________________________________________________

 

  1. I confirm that neither my child(ren) nor anyone in our household has traveled internationally within 14 days prior to my child’s camp session __________ (initials)

 

  1. I confirm that neither my child(ren) nor anyone in our household visited a long-term care nursing home facility within 14 days prior to my child’s camp session __________(initials)

 

  1. I confirm that I will not send my child(ren) to camp if my child(ren) or anyone in our household recently experienced a fever of 100.4 degrees or higher within 14 days prior to or during my child’s camp session __________(initials)

 

  1. I confirm that neither my child(ren) nor anyone in our household recently tested positive for COVID-19, or are awaiting testing results, experienced a cough, shortness of breath, diarrhea, loss of smell or taste, or any other flu-like symptoms 14 days prior to or during my child’s camp session __________(initials)

 

  1. I confirm that neither my child(ren) nor anyone in our household has knowingly been in the vicinity of any individual who has tested positive for COVID-19, or is awiting testing results, experienced a cough, shortness of breath, diarrhea, loss of smell or taste, or any other flu-like symptoms 14 days prior to or during my child’s camp session __________(initials)

 

I confirm that the information given in this form is true, complete and accurate. I understand that if any of these answers change during the week of my child’s camp session that it is my duty to inform the Environmental Learning Center immediately. I understand that if my child has a fever when tested at camp that they will not be able to attend until I can prove that my child has not tested positive for COVID-19.  I further understand that the Environmental Learning Center cannot fully control, manage, or eliminate the risk of the spread of COVID-19 virus even with the implementation of increased protective measures. Furthermore, I understand that the Environmental Learning Center cannot guarantee that my child will stay within 6 feet distance from other campers without face protection during their week at camp. It is my full responsibility to recognize the risks of summer camp and germ exposure when determining whether to send my child to camp. 



Print Parent Name: _______________________________________________________



Parent Signature: ________________________________________________________



Date: __________________________________________________________________