Child's / Participant's Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Please check off *

If TWO OR MORE of the fields in this Section are checked off, please stay home and notify us immediately.

Fever (measured or subjective)

Chills

Rigors (shivers)

Myalgia (muscle aches)

Headache

Cough

Sore Throat

Shortness of breath or any difficulty breathing

Nausea or Vomiting

Diarrhea

Fatigue

Congestion or runny nose

Any other flu like symtoms

None of these

Please check off *

If AT LEAST ONE field in this Section is checked off, please keep your child home and notify us immediately.

Cough

Shortness of Breath

Difficulty Breathing

New loss of smell

New loss of taste

None of these

Please verify if:

Your and/or child has had close contact (within 6 feet of an infected person for at least 10 minutes) with a person with confirmed COVID-19

Someone in your household is diagnosed with COVID-19

You and/or your child has traveled to an area of high community transmission.

Verify that all information on this form is correct to the best of your knowledge *

Yes

No