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Girl Scout Leadership Summit Health Check-In Ticket

Parent/Guardian – Please provide to Troop Leader or at Check-In

Date: _________________

Temp: ________________

Have you, your Girl Scout, or anyone else in your household experienced in the last 14 days any of the symptoms commonly associated with Covid-19, such as headache, fever, loss of smell or taste, fatigue, cough, difficulty breathing, or intestinal symptoms? YES/NO

Have you, your Girl Scout or anyone else in your household been diagnosed with Covid-19 within the past 30 days? YES/NO

Have you, your Girl Scout or anyone else in your household traveled outside of the country within the past 30 days? YES/NO

If you answered yes to any of the above questions, please return home and do not participate in this event.

I understand that participation in the Girl Scout Leadership Summit is voluntary and I have chosen to allow my Girl Scout to participate even though there may be risks associated with the possibility of exposure to Covid-19. I understand that neither my troop leader nor Girl Scouts of North-Central Alabama can be held responsible for illness from exposure to the Covid-19 virus. By signing below, I understand and agree to the statement above.

Full Name of Participant: ____________________________________________________________________________________

Parent/Guardian Signature: ____________________________________________________________________________________