Camp Shiloh Health

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    Camp Shiloh Health
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Please complete form below
Camp Shiloh Health Screening Form

Current Health Screening required by Camp Shiloh

Any person planning to attend the retreat should plan to closely monitor their health and social habits 14 days prior to the retreat date. Anyone exhibiting any cold or flu-like symptoms should NOT attend. Anyone who has pre-existing health conditions, or has a family member with health concerns, should consider not attending the retreat for their health and safety. Please answer questions below based on current health (for the past 14 days)

Name

First Name Last Name

Email
[email protected]

Phone Number
Please enter a valid phone number.

Date

Month Day Year
Date

Has the participant received the Covid-19 Vaccine?

Yes No

Has the participant had a fever (>100.4) or has felt hot or feverish lately? *

Yes No

Does participant have a persistent cough and/or runny nose? *

Yes No

Does participant have any flu-like symptoms? (gastrointestinal upset, headache, fatigue) *

Yes No

Is participant having shortness of breath or other difficulties breathing? *

Yes No

Has participant experienced recent loss of taste or smell? *

Yes No

Has participant been in contact with any COVID-19 positive patients? *

Yes No

Has participant recently traveled to any regions significantly affected by COVID-19? *

Yes No

If answer is YES to any of the lower questions, the participant should NOT attend camp. Any onset of symptoms while at camp will result in isolation and being asked to vacate the premises to ensure the health and safety of others on site. If there are any onset of symptoms within 14 days of departure, participant should notify retreat leader and Shiloh staff immediately. I declare that all statements here are true and accurate to date and consent to all health/safety procedures of the camp.

Signature

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Camp Shiloh Health

Camp Shiloh Health Screening Form