HARMONY Russian Language Centre COVID-19 Return to School Form
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YOU MUST ANSWER THESE QUESTIONS BEFORE RETURNING TO SCHOOL
if more than one child from the same family attending the school please fill out the form for each child separately
If you have symptoms of COVID-19 or if you have been in contact with someone who was diagnosed we ask you to self-isolate and not attend school
Pupil's first name and surname in English *
Pupil's first name and surname in Russian *
Date of birth *
MM
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DD
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Parents/Guardians name(English) *
Phone number *
Email address *
Have you or your child been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *
Have you or your child been advised by a doctor to self-isolate at this time? *
I confirm to the best of my knowledge that this child have no symptoms of COVID-19, not self-isolating or awaiting the results of COVID-19 test. *
Required
If my situation changes after I complete and submit this form I will inform management of the centre. *
Required
I consent for HARMONY Russian Language Centre to collect my personal data. *
Required
I consent for HARMONY Russian Language Centre to take occasional photo/video recording of pupil as part of educational process to be used on website www.harmonylimerick.com and Facebook page Harmony Limerick without any personal information *
Required
Date *
MM
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DD
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YYYY
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