Report a Positive COVID Testing Result
CHILD'S LAST NAME *
CHILD'S FIRST NAME *
CHILD'S DATE OF BIRTH *
MM
/
DD
/
YYYY
PARENT GUARDIAN (FIRST and LAST NAME) *
CHILD'S HOME ADDRESS *
CHILD'S CITY *
CHILD'S STATE *
CHILD'S ZIP CODE *
CONTACT PHONE NUMBER *
CONTACT EMAIL *
CHILD'S LAST DAY AT SCHOOL *
MM
/
DD
/
YYYY
CHILD'S ATTENDED SCHOOL(S) *
Required
CHILD'S GRADE LEVEL *
DATE TESTED *
MM
/
DD
/
YYYY
WERE THERE SYMPTOMS *
TESTING NAME/LOCATION *
IF THERE WERE SYMPTOMS, PLEASE PLACE A CHECK MARK BESIDE THE SYMPTOM(S).
IF THERE WERE SYMPTOMS, WHEN DID THEY START
MM
/
DD
/
YYYY
PLEASE CHECK OTHER ACTIVITES YOUR CHILD IS INVOLVED IN AT SCHOOL *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of Fort Wayne Community Schools. Report Abuse