Student Illness Survey
Do not send the student back to school until you are contacted with further instructions after completing this survey.
Date & Time *
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DD
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YYYY
Time
:
Students Name *
School *
Grade *
What was the last day the student attended school in a building? *
MM
/
DD
/
YYYY
Does the student wear a mask at school? *
Extracurricular Activities (sports, band, quiz bowl, etc). *
Siblings that attend Valley Local Schools *
Please list the siblings that attend Valley *
Does the student ride a bus? *
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