Back To School Health Declaration Form

Back To School Health Declaration Form
Parent/Guardian Name
First NameLast Name
Email
example@example.com
Student Name
First NameLast Name
Student ID
Class
Did you visit countries or cities in the past 21 days?
YesNo
Have you had contact with people with COVID-19 or with people who are suspected with COVID-19 in the past 21 days?
YesNo
Symptoms:
Fever of 100.4 F or greater
Shortness of breath (not severe)
Cough
Sore throat
Chills
Repeated shaking with chills
Muscle Pains
Loss of taste or smell
Headache
Nausea, vomiting or diarrhea
Is the student experiencing any of the symptoms listed above today or has the student experienced any within the last 24 hours?
YesNo
I, undersigned, agree with the following statements:
I am the parent/guardian of the student described above.The personal data provided here is true.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty: