CHILD'S LAST NAME *

CHILD'S FIRST NAME *

CHILD'S DATE OF BIRTH *

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 *

CHILD'S ATTENDED SCHOOL(S) *

CHILD'S GRADE LEVEL *

DATE TESTED *

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

PLEASE CHECK OTHER ACTIVITES YOUR CHILD IS INVOLVED IN AT SCHOOL *