Daily Health & Wellness Check/Participant Screening Form

Per MA guidelines, all participants must print and fill out this wellness check daily PRIOR to attending a Hamilton Wenham Recreation program. Extra copies will be available at every program if you forget to print this form in advance. All responses and individual temperature check results will be maintained on file

Today's Date

Program Participating in?

Today or in the past 24 hours, have you or any household members had any of the following symptoms?

Temperature of 100.0° or above, felt feverish, or had chills

Cough?

Sore Throat?

Difficulty Breathing?

Gastrointestinal symptoms (diarrhea, nausea, vomiting)?

Headache?

New Loss of Smell/Taste?

New Muscle Aches?

Any other signs of illness?

Have you given your child medicine to lower a fever?

In the past 14 days, have you had close contact with a person known to be infected with the novel coronavirus (COVID-19)?

By signing below I (parent/caregiver signature), am reporting all responses accurately. I understand that if any of the above answers are yes, my child will not be allowed to enter the facility and therefore must stay/return home with their parent or caregiver

Sign Here

First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.