Child's First Name *

Child's Last Name *

Today's Date *

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

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? *

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? *

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

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

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? *