21-22 Family Agreement To Screen Student(s)
Families are asked to complete this form on the first of the month, as confirmation that daily screenings of the student(s)' physical health is/are being performed.  
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By completing this form, your family commits to screen their student(s)' daily  physical health.  The presence of any of the symptoms below generally suggests a student has an infectious illness and should not attend school, regardless of whether the illness is COVID-19.
For students with chronic conditions, a positive screening should represent a change from their typical health status.
Daily symptom screening should not try to identify every known symptom of COVID-19. No single symptom indicates someone has COVID-19, and many COVID-19 symptoms can occur when a person does not have COVID-19 or any infectious illness. Instead, use symptom screening to determine if a student currently has an infectious illness that they might pass on to others.
Parent/Guardian Last Name, First name *
Phone number of parent/ guardian *
Email of parent/ guardian
Child #1 Last name *
Child #1 First name *
Child #1 Grade *
Please use this space to provide other information if appropriate.
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