RCS COVID-19 Health Questionnaire for Clubs and Activities

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Please complete the following form and report to your teacher / club sponsor if you answer yes to any of the following questions.

First name *

Last name *

School: *

Name of club or event: *

Students only: parent or guardian name and phone number

Are you experiencing one or more of the following: fever higher than 100.4, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting (2 or more episodes), or diarrhea (2 or more episodes)? *

Yes

Have you had close contact with anybody, including household members, who had a positive COVID-19 test in the last 10 days? (Close contact is within 6' for a total of 15 or more minutes within a 24 hour period with or without a mask.) *

Yes

Are you or anyone in your household awaiting test results from a COVID-19 test? (This does not include if someone is your home is tested regularly for their job.) *

Yes

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