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Mandatory Child Health Check Form

Please select the location you want to visit *
Please select the child *

Does your child or anyone in your household have a fever, cough, sore throat, shortness of breath or a new loss of taste or smell?

Yes
No

Has your child, or another in your household, come in contact with anyone who is confirmed for COVID-19 ?

Yes
No

Are you providing a face mask for your child to wear while at AKP ?

Yes
No

Have you given your child any fever-reducing medication ?

Yes
No

Has your child been in another program, camp, class, or center that has closed in the past 14 days due to COVID-19 ?

Yes
No
Please select the child *

Does your child or anyone in your household have a fever, cough, sore throat, shortness of breath or a new loss of taste or smell?

Yes
No

Has your child, or another in your household, come in contact with anyone who is confirmed for COVID-19 ?

Yes
No

Are you providing a face mask for your child to wear while at AKP ?

Yes
No

Have you given your child any fever-reducing medication ?

Yes
No

Has your child been in another program, camp, class, or center that has closed in the past 14 days due to COVID-19 ?

Yes
No
Please select the child *

Does your child or anyone in your household have a fever, cough, sore throat, shortness of breath or a new loss of taste or smell?

Yes
No

Has your child, or another in your household, come in contact with anyone who is confirmed for COVID-19 ?

Yes
No

Are you providing a face mask for your child to wear while at AKP ?

Yes
No

Have you given your child any fever-reducing medication ?

Yes
No

Has your child been in another program, camp, class, or center that has closed in the past 14 days due to COVID-19 ?

Yes
No
Please select the child *

Does your child or anyone in your household have a fever, cough, sore throat, shortness of breath or a new loss of taste or smell?

Yes
No

Has your child, or another in your household, come in contact with anyone who is confirmed for COVID-19 ?

Yes
No

Are you providing a face mask for your child to wear while at AKP ?

Yes
No

Have you given your child any fever-reducing medication ?

Yes
No

Has your child been in another program, camp, class, or center that has closed in the past 14 days due to COVID-19 ?

Yes
No
Please select the child *

Does your child or anyone in your household have a fever, cough, sore throat, shortness of breath or a new loss of taste or smell?

Yes
No

Has your child, or another in your household, come in contact with anyone who is confirmed for COVID-19 ?

Yes
No

Are you providing a face mask for your child to wear while at AKP ?

Yes
No

Have you given your child any fever-reducing medication ?

Yes
No

Has your child been in another program, camp, class, or center that has closed in the past 14 days due to COVID-19 ?

Yes
No

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