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Southwest Discovery
For Ages 13 – 14
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For Ages 14 – 15
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For Ages 15 – 17
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For Ages 16 – 18
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Coronavirus (COVID-19)
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Covid Questionnaire
Covid Questionnaire
Participant Name
First
Last
Phone
Email
What date does your program start?
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Have you recently experienced any of the following symptoms (Please select all that apply):
Fever (100.4°F/38°C or higher) or chills?
Cough that you cannot attribute to another health condition?
Shortness of breath or difficulty breathing that you cannot attribute to another health condition?
Sore throat that you cannot attribute to another health condition?
Muscle aches that you cannot attribute to another health condition, or that may not have been caused by a specific activity (such as physical exercise)?
Loss of taste or smell?
None of the above
Have you been in contact with an individual who has been ill with flu-like symptoms in the last 14 days?
Yes
No
Have you been diagnosed with COVID-19 in the last 90 days?
Yes
No
Please enter the date you were notified that you were no longer contagious with COVID-19.
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Have you been tested for COVID-19 within the last 7 days?
Yes
No
Covid Test Results
Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.
Upload your test results or if you don't have electronic documentation input your information manually below
When was the test?
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What were the results?
Have you been fully vaccinated for COVID 19?
Yes
No
No, but I have received one dose
I'd rather not say
Which vaccine product did you receive?
Pfizer
Moderna
Janssen (Johnson & Johnson)
Date of first dose
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Date of second does
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1920
Have you received a booster shot?
Yes
No
No, but plan on receiving one prior to coming to DHE.
Date of Booster Shot
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Todays Date
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Participant Signature
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Parent/Legal Guardian Signature
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Parent First and Last Name
Date
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About
About Deer Hill
Staff & Founders
Diversity, Inclusivity & Land Acknowledgement
Service Projects
Wilderness Adventure
Summer Programs
Summer Schedule
Apply
For Ages 11 – 12
Southwest Discovery
For Ages 13 – 14
River & Mountain Adventure
For Ages 14 – 15
Wild Pathways
For Ages 15 – 17
Heart of the Rockies
Southwest Journey
Canyon Country
Wildlands
For Ages 16 – 18
Wilderness Leadership
Group Programs
About Group Programs
School Programs
Private Programs
Facility Rentals
Scholarships
Deer Hill Foundation
Donate
Scholarship Awards
Store
Connect
Contact Us
Directions To Deer Hill
Blog
Alumni
Work at Deer Hill
Video Gallery
Newsletter Sign-Up