Daily COVID-19 Health Screening

Please complete this form before arriving to each day of class/camp. This form must be completed each day by all students, staff, YLP members, and anyone else entering the building for class every day. Please do not come to DMR if you have any COVID-19 symptoms, even if you are vaccinated. If you have symptoms from the list but which arise from other issues according to your doctor, please send us a doctor's note.

If answer to any of the following questions is YES, you must stay home.

Please do not fill this out in advance of the day you attend

Acknowledgement

By entering my name above, I acknowledge the contagious nature of COVID-19 and on behalf of myself, my child(ren), and our family voluntarily, I assume the risk that my child(ren) and I, and any member of the family, may be exposed to or infected by COVID-19 by attending activities with DMR Adventures and that such exposure or infection may result in personal injury, illness, permanent disability, and death. 

What is the nature of your visit?

Are you experiencing any of the following symptoms?

  • Fever/chills with a temperature of 100.4˚F or above
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • Loss of taste or smell
  • Sore Throat
  • Congestion or runny nose
  • Nausea or vomiting and/or diarrhea
AND

If you are not fully vaccinated, have you been in close contact with an individual who has tested positive for COVID-19 within the past 14 days?

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If this error persists, please ask a staff member for a physical copy of this form.