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2. First Name of Unaccompanied Minor*
3. Last Name of Unaccompanied Minor*
5. Street Address:*
7. Instructions
   Unaccompanied minors (age 12-17) visiting the facility without a parent/guardian must have a valid of the health screening questionnaire completed, signed/dated, and submitted by a parent/guardian within 24 hours of arrival. The questionnaire must be submitted separately each visit.
9. 1. I am not currently experiencing fever (100.4 degrees Fahrenheit or higher) and do not have a sense of having a fever.*

   1. Yes
   2. No

   Please circle Yes if you do not
11. 2. I do not have a new cough that cannot be attributed to another health condition.*

    1. Yes
    2. No

    Please circle Yes if you do not
13. 3. I do not have any new shortness of breath that cannot be attributed to another health condition. *

    1. Yes
    2. No

    Please circle Yes if you do not
15. 4. I do not have any new chills that cannot be attributed to another health condition.*

    1. Yes
    2. No

    Please circle Yes if you do not
17. 5. I do not have a new sore throat that cannot be attributed to another health condition.*

    1. Yes
    2. No

    Please circle Yes if you do not
19. 6. I do not have any new muscle aches that cannot be attributed to another health condition or specific activity (such as physical exercise).*

    1. Yes
    2. No

    Please circle Yes if you do not
21. Electronic Signature of Parent/Guardian*
23. Date & Time*
    Date & Time

    Date & Time
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field