Daily Health Screening Form: Classes

Daily Health Screening Form

Staff, children, or youth sick with any illness must stay home. If you or someone in your household is being tested for Covid19, please contact info@youththeatre.org before coming to class. Please answer the following questions BEFORE arriving to Youth Theatre Northwest.
Student Name*

First NameLast Name
Parent/Guardian Name

First NameLast Name
List of possible Covid-19 Symptoms (will be referenced in some of the following questions)

o A cough
o Shortness of breath or difficulty breathing
o A fever of 100.4°F or higher or a sense of having a fever
o A sore throat
o Chills
o New loss of taste or smell
o Muscle or body aches
o Nausea/vomiting/diarrhea
o Congestion/running nose – not related to seasonal allergies
o Unusual fatigue
Have your student or anyone in your household had any of the symptoms listed above that are not attributable to another condition in the past 72 hours or come in contact with anyone with suspected or confirmed COVID-19?*

YesNo
What is your students temperature today (In Fahrenheit)? *
Should be Empty: