LPSS Student COVID-19 Reporting

Please complete this form ONLY if your student has a confirmed positive COVID-19 test result from a medical professional. ALL information provided in this form is confidential.

Student First Name *

Student Last Name *

School *

Student Grade *

Does this student ride a bus? *

Yes

Is this student involved in any school-sponsored extracurricular activities? *

Examples: Soccer, Football, Cheerleading, Dance Team, Robotics Club, ROTC, etc.

Yes

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