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Health Screening Form for Safety Town

  1. The person who completed the online registration should complete this health screen survey for ALL members of the group no more than 24 hours prior to your scheduled visit.

  2. The person who completed the online registration for your visit to Safety Town

  3. If any person in your group is experiencing one of these symptoms, please reschedule your visit.

  4. Fever greater than 99.9*

  5. Uncontrolled secretions*

    that would result in blowing your nose while talking

  6. Flu-like symptoms*

    fever, cough, shortness of breath

  7. Vomiting or Diarrhea*

  8. Loss of sense of taste or smell*

  9. Muscle pain*

  10. Chills*

  11. Leave This Blank:

  12. This field is not part of the form submission.