Sample CoVid-19 Questionnaire
Please answer every question as honestly as possible.
Today's Date: *
MM
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DD
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Child(ren)'s Last Name: *
Child(ren)'s First Name(s): *
Has your child(ren), yourself, or a family/household member tested positive (or been around others who tested positive) for active COVID-19 infection in the past 14 days? *
Has your child, yourself, or a family member shown or been around anyone with any symptoms associated with COVID-19 (listed below) in the past 14 days?: Fever/Chills, Cough, Shortness of Breath, Sore Throat, Muscle/Body Aches, Congestion/Runny Nose, Vomiting/Nausea, Diarrhea, Fatigue, or New Loss of Taste/Smell? *
Has your child taken any medication for symptoms above? *
Has your child, yourself, or a member of your household traveled outside of the tri-state area, and/or have been in large crowds where social distancing could not be maintained, in the past 14 days? *
By typing my digital signature below, I certify that my child(ren) and family have been following CDC guidelines, and have been practicing social distancing and wearing masks when interacting with people when closer than 6 feet, in both indoor and outdoor environments. In signing below, you and your child are also certifying that the information above is complete and accurate. You and your child are also agreeing to comply with the guidelines provided. I also understand that If you or your child do not follow our CoVid19 policies, or answer “yes” to any questions above, that they will not be able to participate in classes, practices, or other activities with SKGA for 14 days, or until cleared by a doctor with a negative test result. *
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