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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Student Name (First and last)
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?
shortness of breath or difficulty breathing
loss of taste or smell
None of the above
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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This form was created inside of Movement Charter School.