Health Check Form
To prevent the spread of novel coronavirus (Covid-19) in our community and reduce the risk of exposure to our staff and students, we require you to complete this screening questionnaire prior to sending your child to Montessori Playhouse. Thank you.

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Name *
Child's Name *
Phone number *
Have you travelled out of Malaysia in the past 14 days?* *
Have you been in contact with a confirmed novel coronavirus (Covid-19) patient in the last 14 days?* *
Have you been in close contact with someone who is under the “Home Quarantine Order” or someone suspected of COVID-19 in the past 14 days?* *
Have you attended or come in contact with someone who attended an event or went to a place associated with COVID-19 outbreak in the past 14 days?* *
If you have any of the following symptom(s), please select check the relevant box(es). *
Required
I declare all the above to be true and correct. By submitting this declaration form, I agree to the collection, use, and disclosure of my personal information above by Branch & Vine Sdn Bhd for the purposes of a precautionary measure against COVID-19 Acute Respiratory Disease in the company’s premises.* *
Required
Form Date *
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