Request edit access
Daily PreScreen
IF YOUR FORM DOES NOT GO THRU PLEASE CALL OR TEXT 413-822-5310.   Please have this form completed 30 minutes prior to your child's pick-up time EVERY DAY. Any questions, please call 413-822-5310.
Sign in to Google to save your progress. Learn more
Date *
MM
/
DD
/
YYYY
Child's Name *
Today or in the past 24 hours, have you or any household members had any of the following symptoms?• Fever (temperature of 100.0F or above), felt feverish, or had chills?• Cough?• Sore throat?• Difficulty breathing?• Gastrointestinal symptoms (diarrhea, nausea, vomiting)?• Fatigue? (Fatigue alone should not exclude a child from participation.)• Headache?• New loss of smell/taste?• New muscle aches?• Any other signs of illness? *
In the past 10 days, have you had close contact with a person known to be infected with the novel COVID-19? *
I understand that my child will be riding with other children from the same classroom ONLY. By signing below you are releasing KidZone Transportation of any liability if you or your child contracts covid-19.  Please sign (type) your name below. *
The phone number I can be reached at today is *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms