Full Name of Participant (first child) *

Full Name of Participant (second child, if applicable)

Full Name of Participant (third child, if applicable)

Body Temperature - must be taken the morning of (Regular body temperature is 98.6F or 37C. A fever is over 100F or 38C) - first child *

Body Temperature - must be taken the morning of (Regular body temperature is 98.6F or 37C. A fever is over 100F or 38C) - second child, if applicable

Body Temperature - must be taken the morning of (Regular body temperature is 98.6F or 37C. A fever is over 100F or 38C) - third child, if applicable

Are any of the above named participants experiencing any of the following symptoms? *

If you indicated Yes to any symptoms above, please indicate which participant is experiencing them.

Have you or any above named participants traveled outside of Leeds and Grenville area within the last 14 days? *

Has a doctor, health care provider, or public health unit told you or the above named participants should currently be isolating (staying at home)? *

Is someone that the above named participant(s) lives with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

In the last 14 days, have you or the above named participants received a COVID Alert exposure notification on their cell phone? *

Have you or any above named participants been in close physical contact with someone who is ill, or been in close physical contact with someone with a confirmed case of COVID-19? *