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Starlight PAC Daily COVID-19 Pre-Screen
To participate in studio activities during the summer, each student must complete this form prior to arriving to the studio.
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* Indicates required question
Email
*
Your email
Student's Name
*
Your answer
Name of person filling out this form
Your answer
Is the student experiencing any of the following symptoms?
*
Yes
No
Fever at or above 100.4°
Persistent coughing
Sore throat
Shortness of breath
Chills
Unexpected muscle aches
Headache
New loss of taste or smell
Abdominal pain, nausea, vomiting, or diarrhea
Yes
No
Fever at or above 100.4°
Persistent coughing
Sore throat
Shortness of breath
Chills
Unexpected muscle aches
Headache
New loss of taste or smell
Abdominal pain, nausea, vomiting, or diarrhea
Has the student had contact with someone who is currently sick?
*
Yes
No
Has the student been diagnosed with COVID-19 in the past three weeks or have reason to believe they have COVID-19?
*
Yes
No
Has the student traveled or had close contact with anyone who has traveled internationally in the past 14 days?
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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