Evening School Daily Health Screening Form
Please complete this form everyday before 5 pm.
Date *
MM
/
DD
/
YYYY
Parent Name *
Student Name *
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? *
Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem)? *
If you have answered "YES" to any of the questions listed above please inform the school and keep your child home.
By printing your name below you verify that the above information is correct.
Parents Name/Sign *
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