COVID-19 Healthy Camper Survey

Dakotas-Minnesota Area United Methodist Camp & Retreat Ministries

All campers and volunteers are required to complete the “Healthy Camper” survey prior to the start of camp. This survey helps our staff gain a better understanding of camper health and COVID-19 exposure and history. Be sure to complete this survey as soon as possible and no later than three weeks prior to your arrival at camp. Planning for a safe and healthy time at camp starts at home.

These survey answers will not necessarily exclude you from coming to camp but may warrant further follow up, including possible testing or self-quarantine time prior to camp attendance. If any follow up is needed, you will be contacted by a camp staff member. Please be as truthful and accurate as possible when answering these questions. NOTE: For adult and family campers, please fill out this survey for each person attending camp.

Camper First Name

Camper Last Name

Contact Phone Number

Contact email

Camp #

Camp Title

Camp Location

1. Within 14 days of the start of camp, will your camper or camper?s family members travel outside of the US and/or travel by airplane? *

Yes

If yes, where and why?

2. Within 14 days of the start of camp, will your camper or camper?s family members attend a gathering of more than 20 people (such as wedding, party, funeral, family reunion, etc.?) *

Yes

3. Within 14 days of the start of camp, will your camper attend or participate in a group program (such as sporting event, YMCA, or after-school program?) *

Yes

4. Does your camper live in a congregate setting (immediate household greater than 8 people, apartment/condo complex, shelter, transitional housing, etc.?) *

Yes

5. In the past 90 days, has your camper tested positive for COVID-19 or been suspected of having COVID-19? *

Yes

a. If yes, date of start of symptoms or positive test:

b. Date that all symptoms fully resolved:

6. In the past 90 days, have any household members tested positive for COVID-19 or been suspected of having COVID-19? *

Yes

a. If yes, date of start of symptoms or positive test:

b. Date that all symptoms fully resolved:

7. If eligible, has your camper been vaccinated? *

Yes

a. If yes, what vaccine brand?

Moderna

Pfizer

Johnson & Johnson

b. Date of first vaccine:

c. Date of second vaccine (if applicable):

d. Date and brand of vaccine booster (if applicable):

8. To provide a healthy camp environment, we ask that all campers and adult volunteers plan to carry out at least one of the following COVID-19 safety protocols. Please check the letter of the options your camper agrees to follow: (Select all that apply, but you must select at least one.) *

a. For the 14-days prior to camp, my unvaccinated camper or adult volunteer will: Intentionally limit exposure outside of our household, always wear a face mask when in public as appropriate, avoid social gatherings when physical distancing is not possible or when others are not wearing face masks, and be diligent about handwashing and sanitizing.

b. My unvaccinated camper or adult volunteer will test for COVID-19 (either Rapid test or RPR Lab test) within 5-7 days of camp and follow quarantine precautions between testing and the start of camp.

c. My camper or adult volunteer has been fully vaccinated and does not need to isolate prior to camp. (Applicable if 2nd vaccine administered greater than 14 days from the start of camp.)

d. I will inform camp if my camper or adult volunteer has had a confirmed case of COVID-19 within 90 days of the start of camp.

e. Other:

For Parent/Guardian:

My signature indicates that I have completed this Healthy Camper survey accurately to the best of my ability. I understand that arriving to camp healthy is vital to a healthy camp for all campers. I understand the importance of providing complete and truthful answers to this screening, so campers are not placed at increased risk for exposure to illness.

Camper/Guardian Signature: *

Date:

COVID-19 Healthy Camper Survey

COVID-19 Healthy Camper Survey

COVID-19 Healthy Camper Survey

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