MCS (Freedom) 21-22 Health Attestation Form
This form is required to be completed daily for all students in order to attend Movement School in-person. Please answer each question honestly in order to keep our scholars and staff safe.
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Email *
today's date *
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Student Name (First and last) *
Grade Level *
Has your scholar been tested and had a positive result or have you been told by a healthcare provider that you are likely positive for COVID-19? *
Within the last 14 days has your scholar been in close contact with anyone that you know has been diagnosed with COVID-19 or has had COVID-19 related symptoms? *
Does your scholar have one or more of the following symptoms? *
Required
Contact number for follow up by school nurse or administration if required *
I consent that I have answered each question to the best of my knowledge and I will exclude my scholar from in-person learning if they have tested positive for Covid-19, been exposed for more than 15 minutes, or shows one or more of the symptoms listed above (insert parent name) *
A copy of your responses will be emailed to the address you provided.
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