Health Statement - Tzofim Shevet Ofek 2020-2021

טופס הצהרת בריאות - שבט אופק 2020-2021

הורים יקרים,

בהתאם להנחיות הסטייט וה- CDC בנושא הקורונה, הינכם נדרשים למלא טופס זה עבור כל אחד מילדיכם הרשומים לצופים ועבור כל אחד מההורים המתנדבים בפעילות, כולל שכב"ג, בכל שבוע מחדש ולפני כל פעילות. אנו מזכירים כי עבור כל חניכי השבט, גם אם הם בני 18, חייב אחד ההורים לחתום על ההצהרה ולא הילד עצמו. חניך שלא יגיע עם טופס מוכן לא יורשה להיכנס לפעילות באותו שבוע.

שימו לב:

ניתן למלא טופס זה רק ביום הפעולה. טופס עם תאריך אחר לא יתקבל.


In the last 48 hours, has your child or someone in your household had any of the following symptoms?
Please check ALL that apply:
Fever of 100 F (37.8 C) or above, or possible fever symptoms like alternating chills and sweating *
Cough *
Trouble breathing, shortness of breath or severe wheezing *
Chills or repeated shaking with chills *
Muscle aches *
Sore throat *
Loss of smell or taste, or a change in taste *
Nausea, vomiting or diarrhea *
Headache *
Fatigue *
Congestion or runny nose (Which is not allergic or chronic) *
Has your child or someone in your household come into close contact (within 6 feet) with someone who has a laboratory-confirmed COVID-19 diagnosis in the past 14 days? *
In the last 14 days, has your child or someone in your household visited one or more of the affected states/countries/regions listed in as requiring 14 days of quarantine? *
If your child or any member in your household has had any of the above symptoms, your child cannot join the activity.
In addition, if any of the above questions is Yes, your child cannot join the activity, unless he has been tested negative for COVID-19 or has completed a 14 days of quarantine.
Please check: *
Child/Adult CAN participate in the activity. Thank you
Please check: *
Child/Adult CANNOT participate in the activity. Take care!
Has your child tested negative for COVID-19 during the past 72 hours? *
Has your child been in quarantine for the past 14 days? *
Please check: *
Child/Adult CANNOT participate in the activity, unless he has been in quarantine for 14 days or tested negative for COVID-19 72 hours prior to the activity.
Please check: *
Child/Adult CAN participate in the activity, with a valid negative COVID-19 test result or completing 14 days of quarantine. Thank you
Please sign: *