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Family Faith COVID-19 Screening
Please complete before attending Family Faith classes.

Please answer “YES or “No” to the following questions for every member of your household. If you answered YES to ANY of these questions for any household member, please stay home and do not come to Family Faith or Mass today.
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Email *
Today's Date *
MM
/
DD
/
YYYY
Family (Last) Name *
Please list your oldest student's first name, grade, and temperature this morning *
Please list your next child's first name, grade and temperature this morning
Please list your next child's first name, grade, and temperature this morning
In the past 48 hours, has anyone in your household: *
YES
NO
had a new fever of 100.4 or greater?
had a new cough not attributed to another health condition?
had a new shortness of breath that cannot be attributed to another health condition?
lost any sense of smell or taste?
had a new sore throat that you cannot attribute to another health condition?
had new muscle aches that you cannot attribute to another health condition or to a specific activity (such as physical exercise)?
In the past 48 hours, has anyone in your household had close contact with a person with a suspected or confirmed case of COVID-19? *
I agree that if anyone in my household shows any of the above symptoms, that we will not attend Family Faith classes/programs. If anyone in my household tests positive for COVID-19 after attending a Family Faith class/program, I will notify St. Mary Magdalen ASAP. Please enter your name below as your electronic signature. *
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