OUTDOOR OUTREACH COVID-19 PRE-TRIP AGREEMENT AND SCREENING

As Outdoor Outreach reopens in-person programs, the health and wellness of everyone participating is our top priority. We are adapting our programs to local and state health guidelines, as new updates are released, we will continue to stay up to date on our practices and policies.

On each program Outdoor Outreach staff will be taking the following precautions:

Temperature checks upon arrival for participants and staff, each day.
The use of cloth face coverings when feasible and most essential in times when physical distancing is difficult.
Increased use of hand washing stations and sanitizer
Maintaining a physical distance of 6' feet from others as frequently as possible
Individual servings of pre-packaged lunches, snacks and water
Limiting the sharing of any equipment or supplies
Cleaning and disinfecting frequently touched surfaces
Provide personal protection items for anyone that is not able to supply their own
The same set of staff members will be consistent with each program as much as feasible.
Group sizes will remain at a maximum 12 participants, with a minimum staff ratio of 1 to 5.
Transportation will usually be provided by parent/guardian to the activity location. (On occasion this may not be the case)
If transportation by parent/guardian is not feasible to the activity location, please contact Outdoor Outreach for alternative options.

General Information

Parent/Guardian First Name

Parent/Guardian Last Name

Child/Participant First Name

Child/Participant Last Name

Phone

Program Being Attended with Outdoor Outreach:

Start Date of Program:

Address Line 1

Address Line 2

City

State/Province

Postal Code

Consent to Day of Health Screening

Participant agrees to be checked, with the above health screening, upon arrival of the day of the program.
Child/Participant Initial here:

If under 18 years old, the participants parent or guardian, agrees to have the participant be checked, with the above health screening, upon arrival on the day of the program.
Parent/Guardian Initial here:

Should a participant communicate that they may have the COVID-19 virus, the symptoms, or have been in close contact with someone who has been diagnosed with, tested for, or quarantined as a result of COVID-19, then they should not attend Outdoor Outreach programs or must be sent home immediately and shall not be permitted to return for at least 14 days, or without doctors release.

Outdoor Outreach staff will reach out to participant/parent if information shared on this form indicate they may have or have been exposed to COVID-19 and cannot participate.

*Close contact is defined as being within 6 feet of a person who has or is likely to have COVID-19 for more than 15 minutes; or having unprotected contact with the body fluids and/or secretions (including but not limited to being coughed on or sneezed on, sharing utensils or drinking out of the same container) of a person who has or is likely to have COVID-19.

SD Public Health Order

Agreement

Health Specific:
☐ Make use of a cloth face covering as needed and required

☐ Maintain at least 6 foot distance between one another and follow other CDC guidelines whenever possible

☐ Practice proper respiratory etiquette and cover all coughs, sneezes, etc.

☐ Sharing of equipment and supplies such as food, water, cell phones, etc., shall be avoided whenever possible
☐ Hand washing frequently and thoroughly using antibacterial soap and warm water
☐ If on the day of a program, the participant exhibits symptoms relating to COVID-19, parent/guardian will be contacted to pick up the participant from the activity location.
☐ If a participant exhibits symptoms relating to COVID-19 within 48 hours of the completion of a program the parent/guardian/participant agree to inform Outdoor Outreach as soon as possible.

Child/Participant Initial here:

Parent/Guardian Initial here:

Agreement

I (or the parent/guardian of the minor participant) am aware participating in Outdoor Outreach activities entails certain risks. I am voluntarily engaging in in-person activities and I am willing to assume the associated risks. I agree to abide by the COVID-19 procedures outlined by Outdoor Outreach, observe local and state government policies and regulations related to exposure prevention, as well as CDC guidelines. I will take all necessary and reasonable precautions to avoid COVID-19 exposure; however, I acknowledge that neither I, nor Outdoor Outreach, can eliminate all risks created by the COVID-19 pandemic, including the potential for exposure to the virus while at, or traveling to, an Outdoor Outreach activity, regardless of whether I/they adhere to the health and safety procedures established by local governments and the CDC, or other recommended hygiene and social distancing practices.

Student Signature

Age

Date Signed

Parent/Guardian Signature

Date Signed

Fever of 100.4 °F or greater	Cough	Shortness of breath	Diarrhea
Fatigue	Headache	Muscle aches	Nausea
New loss of taste or smell	Sore throat	Congestion or runny nose	Vomiting

OUTDOOR OUTREACH COVID-19 PRE-TRIP AGREEMENT AND SCREENING

As Outdoor Outreach reopens in-person programs, the health and wellness of everyone participating is our top priority. We are adapting our programs to local and state health guidelines, as new updates are released, we will continue to stay up to date on our practices and policies.

The following agreement and health screening helps to bring to light information for our staff team. This information is confidential and will only be shared with pertinent Outdoor Outreach staff members.