COVID Symptoms Self Evaluation Form - Lake Bluff Park District

Health Screening

The Lake Bluff Park District is committed to the safety of employees, patrons, and community, including during the COVID-19 pandemic. Patrons will be required to self-assess using these questions each day prior to coming on-site. If the answer is “yes” to any question, please do not come on-site to prevent the spread of illness. In addition, patrons will also be required to abide by the Lake Bluff Park Districts rules on social distancing, hand washing, and face covering during the time they are at their facility.

Child's Name*
Is your child experiencing any symptoms related to COVID-19, i.e. fever, cough, sore throat, shortness of breath, chills, muscle pain, new or unusual headache, new loss of taste or smell, fatigue, congestion or runny nose, nausea or vomiting, or diarrhea?*
- Yes
- No
Has your child been in close contact * with someone who has been diagnosed with COVID-19 in the last 14 days?*
- Yes
- No
* Close contact includes household contacts, intimate contacts, or contacts within 6 feet for 15 minutes or longer.
Has your child tested positive for COVID-19 in the last 14 days?*
- Yes
- No
Consent*
By checking this box I accept the terms below.
By coming to the facility you acknowledge that you have in fact conducted this self-assessment and the information provided above is true and accurate to the best of your current knowledge and beliefs. You also agree to abide by the Lake Bluff Park Districts rules on social distancing, hand washing, and face covering during the time spent in their facility.