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JCC MidWestchester

Children & Teens

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Daily Health Check Questions

If you do not have a smartphone, please print out and complete the following form and bring it with you to JCCMW

Name *First (Given) Name – Last Name (Surname) …………………………………………………

Email (This sends the results to your email, enabling documentation.) …………………………………………………

Select one of the following that best describes yourself:                             
I am a JCC MEMBER               I am a JCC GUEST/VISITOR               I am a JCC STAFF MEMBER      

According to the U.S. Centers for Disease Control and Prevention & the World Health Organization, COVID-19 Symptoms include:

  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

Are you experiencing any of the COVID-19 related symptoms noted above?  Please circle:

Yes

No

Are you living with or caring for an individual who is a suspected or confirmed case of COVID – 19? Please circle:

Yes

No

Have you been in contact with anyone known or suspected to have COVID – 19 in the last 14 days?  Please circle:

Yes

No

Have you tested positive for COVID-19? Please circle:

Yes

No

Have you travelled out of the Tristate area (New York, New Jersey, Connecticut) in the past 14 days? Please circle:

Yes

No

I certify all the information provided is shared to the best of my ability.

Please sign and date here: ……………………………………………………………………..