Summer Covid Daily Health Screening Form
Date *
MM
/
DD
/
YYYY
Student Name *
Self-Declaration By Student:
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? *
Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem)? *
By printing your name below you verify that the above information is correct.
Parents Name *
Submit
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