About Us
Cub Scouts
Scouts BSA
Announcements
Events
Sign Up

COVID-19 Screening Questionnaire

Before entering a meeting or event, any attendee, including Scouts, Leaders, or other visitors, must have a completed screening questionnaire and undergo a temperature check. Any person with a temperature of or above 100.0 F or with a YES answer to a question below will not be admitted to the meeting/activity. This information will be deleted from this website database 30 days after the date submitted.

Cub Scouts or Boy Scouts?(Required)

Is this for an activity run by Cub Scouts (Pack 334) or Boy Scouts (BSA Troop 334)?

Cub Scouts

Boy Scouts

Individual or Family?(Required)

Is this for one person, or for multiple people from the same household?

One Person

Family

Name of Individual Attending

Name(Required)

First Last Youth or Adult?

Names of Family Attending

All family members listed must be from the same household.

How Many from Your Family?(Required)

Please select how many people, up to 6, from your household will be included on this form. If you need to include more than 6 people, please use multiple forms.

Name(Required)

Name of person completing this form.

First Last Youth or Adult?

Name(Required)

First Last Youth or Adult?

Name(Required)

First Last Youth or Adult?

Name(Required)

First Last Youth or Adult?

Name(Required)

First Last Youth or Adult?

Name(Required)

First Last Youth or Adult?

Screening Questions

The following questions MUST be answered by the adult participant or by parent/legal guardian of youth under age 18. “You” refers to the person requesting entrance to the meeting/event/property.

Question 1(Required)

Are you or anyone in your household awaiting test results for COVID-19 or experiencing symptoms of COVID-19 including fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea? (List as per CDC website 8/3)

Yes

Question 2(Required)

Did you take any medications to lower a fever in the past 24 hours?

Yes

Question 3(Required)

Have you been in close contact (within 6 feet for 10 minutes or more) with anyone who tested positive for COVID-19 in the past 14 days? **Healthcare professionals who work in a facility with a defined PPE and COVID-19 testing/monitoring policy in place can answer no to this question.”

Yes

Attention: If you answer yes to this question you may not attend this activity.

Confirmation(Required)

I acknowledge that the above information is true and correct to the best of my knowledge. I understand that these questions are intended to reduce the potential of, but cannot eliminate, exposure to COVID-19. I agree to contact COL if this participant tests positive for COVID-19 within 14 days of attendance at a meeting, activity, or council property. We recommend those in the higher-risk categories as defined by the CDC stay home to reduce your risk of exposure.

Yes

Contact Information

You must be an adult participant or the parent/legal guardian of youth under age 18 to complete this form.

Name(Required)

Name of person completing this form:

First Last

Contact Phone(Required)

Contact Email(Required)

Enter Email Confirm Email

Yourself or Someone Else?(Required)

Are you completing this form for yourself, or are you completing it for someone else because you are the parent/guardian ?

Self

Someone Else / Family

Relationship(Required)

What is your relationship to the person or people you are completing this form for? (Parent, Grandparent, etc.)

Cub Scout Pack 334 and Scouts BSA Troop 334

Cub Scouts meet every Friday at 7:00pm and Scouts BSA meet every Monday at 7:30pm
Leverington Presbyterian Church
6301 Ridge Avenue, Philadelphia, PA 19128
Contact Us | Our Policies | Parent's Facebook Group | Directions

Cub Scout Pack 334 and Scouts BSA Troop 334 are part of the Cradle Of Liberty Council.
If we are not local to you, you can click here to find a unit in your area.