Camp Shiloh 2021

Self-Screening Health Questionnaire

We are grateful for your partnership in providing a safe and healthy camp environment at Camp Shiloh. The best retreats start with healthy guests and this begins at home. We ask all guests to take part in a self- screening, answering yes or no to the following questions.

Please complete the form below

Camper Name

First Name

Last Name

Have you or anyone in your family/group experienced any of the following symptoms in the 14 days prior to arriving at Camp Shiloh?

● Fever of 99.6 or greater ● New or worsening cough ● Shortness of breath ● New or unexplainable sore throat ● New loss of taste or smell ● Unexplainable diarrhea or vomiting ● Muscle or body aches

Yes

No

Have you or any guests in your group been in contact with someone with COVID-19 in the 14 days prior to arriving at Camp Shiloh?

Yes

No

Have you or any guests in your group been diagnosed with COVID-19 in the 14 days prior to arriving at Camp Shiloh?

Yes

No

If you answered “YES” to any of the above questions, please call the Camp office at (903) 855-1800 to discuss your situation and options prior to arrival. It is possible that we will ask that guests to reconsider their attendance at Teen or Youth Camp at this time. COVID-19 AND PRE-EXISTING CONDITIONS Individuals who are 65 and older or those with known high-risk medical conditions such as cardiovascular disease, respiratory disease, diabetes, or immuno-compromised, are at an increased risk of severe illnesses if COVID-19 is contracted and should consider not participating or taking extra precautions. GUEST GROUP ACKNOWLEDGEMENT I hereby state that I have completed this Self-Screening Health Questionnaire. I also acknowledge that despite Camp Shiloh's reasonable efforts to mitigate the spread of communicable disease, participating in Camp activities may result in exposure to COVID-19 or other communicable diseases, which could result in quarantine measures, serious illness, disability, or death. If I am experiencing any symptoms related to a communicable disease on the day of visiting Camp Shiloh, I will remain at home.

By typing your name in this box, you are agreeing that you have read all of the self-screening information and have answered honestly to the best of your ability.

Parent/Guardian Full Name

By typing your name in this box, you are agreeing that you have read all of the self-screening information and have answered honestly to the best of your ability.

Date

MM

DD

YYYY