Youth Ministry Event Health Form

Please fill out for your child before attending a Youth Ministry Event

Name

This address will receive a confirmation email

Phone

Which event is your child attending?

Please select one option.

HSYG Middle School Midweek Confirmation

COVID 19 Questionnaire

In order to better assure the safety of our church community, we ask that you please review and answer the questions below; then confirm with Patrick that you have done so prior to arriving for your Youth Ministry Event.

If you answer ‘YES’ to one or more of the following questions, you may not attend the event.

Have you or anyone in your household tested positive for COVID-19 (within the last 14 days) or is awaiting results of a COVID-19 test?

Please select all that apply.

YES NO

Do you or anyone in your household have any of the following symptoms?

Please select all that apply.

Fever over 100.4 degrees Cough Sore throat Headache Nasal congestion or runny nose Shortness of breath or difficulty breathing Fatigue; unexplained muscle or body aches Loss of taste or smell Nausea, vomiting, or diarrhea Repeated shaking with chills None Of The Above

In the past 14 days, have you or anyone in your household had close contact with someone who has tested positive for COVID-19 or exhibited COVID-19 symptoms (as defined above)? Close contact means being within 6 feet for more than 10 minutes.

Please select all that apply.

YES NO

Have you or anyone in your household traveled in the last 14 days?

Please select all that apply.

YES NO

If yes, please tell us where?

Description

Please fill out for your child before attending a Youth Ministry Event

Youth Ministry Event Health Form

Description

Please Fix the Following