Student Name *

First Name

Last Name

Does your child have a temperature of over 100 degree? *

Yes

No

Has your child exhibited any COVID-19 symptoms in the last 24 hours? *

e.g. cough, shortness of breadth, fever, chills, headache, muscle pain, new loss of taste or smell, vomiting, nausea, diarrhea

Yes

No

Has your child been in contact with anyone who has been either diagnosed with COVID-19 or quarantined in the last 10 days? *

Yes

No