October 22, 2020
Girl Scout Nation’s Capital Gathering COVID-19 Health Pre-Screen
Event Information
Event: _____________________________________________ Date: _________________ Time: __________
Location: ______________________________________________________________________________
Submit to: _______________ at ___________________________ after ________________________________________
(Name) (email or physical location for paper form) (submit between day/time for email or upon arrival for paper form)
Pre-screen completed no more than 24 hours prior to the gathering. Form required for every participant/attendee for every event.
Dear Girl Scout Family:
To protect our members and keep our communities healthy and safe, participants at all Girl Scout gatherings (troop
meetings, activities, trainings, etc.) are required to meet health requirements, wear a face covering
, wash hands and use
social distancing. Please review the statements below and sign form to verify participant meets all health requirements.
Participant Name: _______________________ Email: _______________________________ Phone: ________________
1. I have not experienced any of the following symptoms in the last 48 hours.
Fever
Cough
Shortness of breath or difficulty breathing
Chills
Muscle pain
Headache
Sore throat
New loss of taste or smell
Nausea
Vomiting
Diarrhea
2. I have not had a fever over 100 degrees, without the use of fever reducing medications, within the last 48 hours.
3. I have no known exposure to COVID-19 or been in close contact with anyone that has tested positive in the last 14
days.
4. I am not waiting on the results of a COVID-19 test.
5. I have not traveled outside the District of Columbia, Maryland, Virginia, and West Virginia in the past 14 days.
The below signature indicates that participant meets all health requirements and will adhere to all Girl Scout gathering
safety precautions. Please note, contact information may be released to local health department in the event of a
confirmed COVID infection. Information will be used for contact tracing.
Participant/Guardian Signature: ___________________________________________ Date: ___________________
(Guardian signature required if participant is 17 and younger)
For Event Organizer Use (Optional)
Group Assignment: _____________________ ________________________ __________________________
Unit Assignment: _______________________ ________________________ __________________________
Transportation: ________________________ ________________________ __________________________
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