Richlands Regional Camp Meeting : Richlands SDA Church Cherryville BC

Email

Phone

Name & Age of Campers (including yourself)

List Allergies (if any)

Do you have a fever?

Yes No

Do you have any of the following signs or symptoms? New onset of cough Worsening chronic cough Sore throat Shortness of breath Difficulty breathing New loss or decrease in sense of taste or smell Runny nose Sneezing (not allergy related) Hoarse voice Nasal congestion Chills Headache Unexplained fatigue or malaise Difficulty swallowing Nausea/vomiting, diarrhea, abdominal pain

Have you traveled or had close contact with anyone who has traveled in the past 14 days?

Yes No

Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19?

Yes No