Elm City - Wilson County Schools 2020-2021 K-12 Symptom Screening Parent / Guardian Attestation

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Child's First Name *

Child's Last Name *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Has your child had close contact (within 6 feet for at least 15 minutes) in the last 14 days with someone diagnosed with COVID-19, or has any health department or health care provider been in contact with you and advised you to quarantine? *

Yes: Your child should not be at school. Your child can return 14 days after the last time he or she had close contact with someone with COVID-19, or as listed below.

No: Your child can be at school if your child is not experiencing symptoms.

Does your child have ANY of the following symptoms? If your child has ANY of these symptoms, he or she should stay away from other people, and you should call your child’s health care provider. *

Fever

Chills

Shortness of breath or difficulty breathing

New cough

New loss of taste or smell

None

Required

Has your child been diagnosed with COVID-19? If your child is diagnosed with COVID-19 based on a test, their symptoms, or does not get a COVID-19 test but has had symptoms, they should not be at school and should stay at home until they meet the criteria below. *

Yes

Please type your full name in agreeance of the attestation form. *

Please enter today's date. *

YYYY

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