ALPHA KAPPA ALPHA SORORITY , INCORPORATED ® COVID-19 SCREENING QUESTIONNAIRE & WAIVER This form must be completed by all participants before the in-person activity . PLEASE PRINT LEGIBLY .
First Name : ____________________________________________________________ Last Name : ____________________________________________________________ Email Address : _________________________________________________________ Mobile Number : ________________________________________________________
Temperature *: ____________ * Temperature will be taken by the sponsoring chapter / event organizers prior to entry .
Are you fully vaccinated ? _____ Yes _____ No * Proof of vaccination is required before entry will be permitted .
Have you been diagnosed positive with COVID-19 within the last 14 days ? _____ Yes _____ No * If YES , please provide documentation of a subsequent negative test .
Have you experienced any of the following symptoms : fever , shortness of breath or difficulty breathing , runny nose , loss of taste or smell , dry cough , sore throat , chills , muscle pain , headache , diarrhea or vomiting ? _____ Yes _____ No
Have you been exposed to someone with a suspected or confirmed case of COVID-19 within the last 14 days ? _____ Yes _____ No * If YES , please provide documentation of a subsequent negative test .
Have you traveled internationally within the last 14 days ? _____ Yes _____ No
If participant answers “ YES ” to any of the questions above , immediately notify the sponsoring chapter / event organizers and await further instructions before permitting entry .
_____________________________________________ Participant / Parent / Guardian ’ s Signature
____________ Date
* If the participant is minor under 18 years of age , the parent / guardian must complete and sign this form on the minor ’ s behalf and indicate relationship to the minor .