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San Francisco Achievers Health Assessment Form
San Francisco Achievers Health Assessment description:
Due to Coronavirus pandemic (COVID-19) and San Francisco moving through the reopening phases, San Francisco Achievers will host a variety of programs and activities that will have a combination of a virtual and in-person sessions. For the in-person sessions, we will require all students to:- Wear a face covering. - Wash hands at least twice during each two hour summer session. - Adhere to social distancing protocols by maintaining at least a six foot distance from all participants.Bathrooms and hand sanitizer will be available to all participants. Our staff will also ensure that the meeting areas are clean before and after the sessions. We plan to have a small number of opt-in activities take place in-person. The health and wellness of your student is important to us and we require the following questions and your signature be received before your student can participate in the in-person sessions.
Are you fully vaccinated?
Yes
No
Has your student left the state of California within the last 30-days?
Yes
No
Has anyone in your home been diagnosed with the Coronavirus?
Yes
No
Has your child had a fever now or in the last two weeks?
Yes
No
Has your child been hospitalized within the last two weeks?
Yes
No
Has your child had contact with anyone outside of your household?
Yes
No
Does your child have any pre-existing conditions? If yes please list.
Please expand on any Yes answers from above:
In case of an emergency, please complete the info below:
Contact's Name
*
First
Middle Initial
Last
Relationship To Student
Home Phone
Cell Phone
*
Text Message Ok?
Yes
No
Choose Primary Phone
Home
Cell
Authorization
*
I give permission for my child to participate in San Francisco Achievers in-person activities.
Child's Name
*
First
Middle Initial
Last
Parent/Legal Guardian Signature
My signature affirms my support of my student to participate.
Name
This field is for validation purposes and should be left unchanged.
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