March 1, 2021
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 24 hours.
Shortness of breath or difficulty breathing
Muscle pain
Sore throat
New loss of taste or smell
2. I have not had a fever over 100 degrees, without the use of fever reducing medications, within the last 24 hours.
3. I have not tested positive for COVID in the last 10 days.
4. I have no known exposure to COVID-19 or been in close contact with a COVID positive individual in the last 10 days.
5. I am not, nor is anyone in the household, waiting on the results of a COVID-19 test.
6. I have not traveled outside Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia in the past
10 days. Or I have taken a COVID test day 5 or later after return from travel and received a negative test result.
Please note, that according to CDC guidelines, even if you are vaccinated, there is a possibility of carrying the virus after
an incident of exposure. Please continue to use all precautions to help stop the spread of COVID-19.
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: ________________________ ________________________ __________________________