2021 Student Travel Declaration
LJA students planning to travel out of state must inform the School Nurse via this form. This form is for out-of- state travel only and must be submitted regardless of vaccination status.
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Email *
Student Last Name(s) *
Student First Name(s) *
Parent Contact Name *
Parent Contact Number *
Student Grade (if more than one child, please check all that apply)
Date of Departure
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/
DD
/
YYYY
Date of Return *
MM
/
DD
/
YYYY
Provide Testing Date (vaccinated: 3-5 days post return from travel) or return date (unvaccinated: 3-5 negative test or 10-day home quarantine *
Captionless Image
MM
/
DD
/
YYYY
Vaccinated Status *
Required
Please read current travel policy protocols: *
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Required
Comments:
A copy of your responses will be emailed to the address you provided.
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