Southeast Polk High School - Fine Arts Student Wellness Check

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Complete this form prior to entering Southeast Polk campus or any district facility for the purpose of a school related fine arts activity. If you answer “YES” to any of the following questions, do not come to the high school campus and notify your coach/director.

Thank you for helping to keep the Southeast Polk community healthy and safe.

Email *

What is your name? (Last, First) *

What is your grade? *

9th

10th

11th

12th

If you are participating in Southeast Polk fine arts practice today, please check the activity below. *

Marching Band

Show Choir

Other:

Required

Have you had a consistent cough in the last 24 hours? *

Yes

Have you had a sore throat in the last 24 hours? *

Yes

Have you had shortness of breath in the last 24 hours? *

Yes

Have you vomited in the last 24 hours? *

Yes

Have you had chills or repeated shaking in the last 24 hours? *

Yes

Have you had muscle pain (unrelated to your activity) in the last 24 hours? *

Yes

Have you had a headache in the last 24 hours? *

Yes

Have you had a loss of taste or smell in the last 24 hours? *

Yes

Have you had close contact, or cared for someone with COVID-19? *

Yes

Have you had a fever in the last 24 hours? *

Yes

What is your temperature? If you have a temperature above 100.4 degrees, you may not participate in a Southeast Polk activity or be on campus. *

A copy of your responses will be emailed to the address you provided.

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