Student COVID Symptom-Free Self-Certification - January, 2021
Parents / guardians and students over 18 years of age or emancipated as mature minors under Illinois law are asked to certify that the student is free of any COVID-19 symptoms prior to entering a District school bus or school building.

All students intending to attend any in-person session during modified remote learning or hybrid learning must have their monthly parental/self-certification health screening form turned in prior to being scheduled to attend any in-person session.
Email address *
Student Last Name *
Student First Name *
Student ID Number *
Student ID # is 6 digits
Building *
Grade Level *
Parent/Guardian Name *
Personal Telephone Number *
1. Symptom Acknowledgement
I am acknowledging that I will not send my student to school if any of these symptoms exist.

- Temperature in excess of 100.4° Fahrenheit
- Shortness of breath or difficulty breathing
- Muscle and body aches
- Sore throat
- Congestion or runny nose
- Diarrhea
- Cough
- Fatigue
- Headache
- New loss of taste or smell
- Nausea or vomiting
- Positive test for COVID-19
- Suspected or diagnosed case of COVID-19
2. Contact Acknowledgements

I am acknowledging that I will not send my student to school if, within the 14 days prior to visiting the school, he or she has been in close contact with an individual who has either tested positive for or is suspected of having COVID-19, during the highly contagious period.

For the purposes of this screening, “close contact” is defined as having been within six feet of the individual for a period of at least 15 minutes, or residing in the same household as the individual. For the purposes of this screening, the highly contagious period is defined as starting from 2 days prior to the onset of symptoms or, if asymptomatic, from 2 days prior to the positive test date, until isolated.
By selecting 'Agree' to this question I am acknowledging that I agree with BOTH of the acknowledgements as stated above. *
In-person Attendance
If a student has any of the symptoms listed in item #1 above, or your student does not meet the contact requirements in item #2 above, they should not come to school on any day they are scheduled for in-person learning, and a parent/guardian should call the student's school attendance line to provide the information requested. Someone will contact you about the school’s return to school protocol and your child’s opportunity to receive educational services during their absence.

If your student meets the requirements for attendance shown in items #1 AND #2 above, on a planned attendance day please send your student to school as scheduled for in-person attendance.
Signature
The electronic signature below and its related fields are treated by Huntley Community School District 158 like a physical handwritten signature on a paper form.

By submitting this form I verify that all the information provided is true and correct to the best of my knowledge.
Signature (enter your name) *
A copy of your responses will be emailed to the address you provided.
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