Child Information

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Child Information

Daily form must be completed by a parent before the child can be admitted into the school building.

Child's First Name *

Child's Last Name *

Today's Date *

YYYY

Has your child experienced in the past 14 days, any of the following symptoms? *

Dry Cough

Diarrhea

Vomiting

Fever (100 degrees or higher)

Sore Throat

New Loss of Taste or Smell

Shortness of breath or difficulty breathing

Head or muscle aches

None of the above

Required

In the past 14 days, has your child or anyone in your household been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *

Yes

In the past 14 days, has your child or anyone in your household been in close proximity to anyone who has tested positive for COVID-19? *

Yes

Has your child or anyone in your household been tested for COVID-19 and are waiting to receive test results? *

Yes

Have you traveled outside of the state of PA in the last 14 days? *

Yes

If so, was it a state listed on the PA "No Travel List"? If you have traveled, or plan to travel, to an area where there are high amounts of COVID-19 cases, it is recommended that you stay at home for 14 days upon return to Pennsylvania. Please list your destination below. If you have NOT traveled, please write "no travel" *

In the last 14 days have you been with a group larger than 25 people where you were not able to social distance or where a mask? *

Yes

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