SUMMER YOUTH PROGRAM COVID 19 – 14 DAY HEALTH ATTESTATION FORM

    I certify that my child is in good health and has showed no signs of illness 14 days prior to attending MHNA Summer Youth Program. All others that reside in my household and those that I have been in contact with 14 days prior to attending summer program are in good health and show no signs of illness. I understand the importance of monitoring for symptoms and can attest no one in my household show any of the following symptoms;

    • Fever
    • Cough
    • Shortness of breath or any difficulty breathing
    • Chills or repeated shaking with chills
    • Headache
    • Sore throat
    • Loss of taste or smell Gastrointestinal upset or diarrhea

    I certify that the camper has had no contact with anyone who has tested positive for COVID 19 or anyone who had contact with someone who tested positive for COVID 19 in the past 14 days. I understand that if my child exhibit any of these symptoms leading up to the program or while the program is in session, I will notify MHNA Summer Youth Program immediately and seek the advice of a physician.