Summer Recreation Program COVID-19 Daily Screening Questionnaire 2021 SUMMER PROGRAM COVID-19 HEALTH DECLARATION FORM To prevent the spread of COVID-19, this form MUST be submitted BEFORE your child arrives at Summer Program each day. Date* MM slash DD slash YYYY Child's name* First Last Name of parent/guardian submitting this form* First Last Have you, the child, or anyone in your family travelled outside of the province in the last 14 days?* Yes No Have you, the child, or anyone in your family been in close contact with a known or suspected case of COVID-19?* Yes No Have you, the child, or anyone in your family been in close contact with a person with acute respiratory illness who has travelled outside of Newfoundland and Labrador within 14 dyas prior to their illness onset?* Yes No Have you, the child, or anyone in your family had any symptoms of the illness (as described below:*1. Fever or signs of a fever, such as chills, sweats, muscle aches, and lightheadedness) 2. Cough 3. Headache 4. Runny nose 5. Painful swallowing 6. Diarrhea 7. Loss of sense of smell or taste 8. Unexplained loss of appetite 9. Small red or purple spots on hands and/or feet? Yes No By checking the box below I acknowledge and confirm I, the child I am submitting on behalf of, is not experiencing any flu-like sypmtoms and agree to immediately report if symptoms occur.* I agree
