Full Name
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Email
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Phone
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Do you (staff member) or your child (Parents/Legal Guardians) have any of the following symptoms?
Fever, chills, or shaking chills
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Yes
No
Cough (not due to other known cause, such as chronic cough/asthma/allergies)
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Yes
No
Rapid or difficulty breathing or shortness of breath (without physical activity)
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Yes
No
New loss of taste or smell
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Yes
No
Flushed cheeks
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Yes
No
Sore throat
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Yes
No
Headache (in combination with other symptoms)
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Yes
No
New muscle aches or body aches
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Yes
No
Nausea, vomiting, or diarrhea
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Yes
No
Fatigue (in combination with other symptoms)
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Yes
No
Nasal congestion or runny nose (not due to other known causes, such as allergies) in combination with other symptoms
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Yes
No
Any other signs of illness
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Yes
No
Have you, someone in your immediate household or your child had contact with someone in the previous 14 days with a confirmed or presumptive diagnosis of COVID-19 or someone who is ill with a respiratory illness?
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Yes
No
Please check
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I attest that the answers I have provided in this form are all true.
Submit