Student/Parent/Guardian COVID Release Form
Student/Parent/Guardian COVID Release Form
In consideration of my child being allowed to attend and participate in-person at the school for school related activities to include but not limited to educational, co-curricular and extracurricular programs, the undersigned acknowledges and agrees that:
All parents of students must take the student’s temperature every day before the student may come to school. Additionally, all parents of students must review the checklist of COVID-19 symptoms below every day before the student comes to school. Any student who has an elevated temperature or symptom of COVID-19 appearing on the checklist below MUST stay home from school and the fever and/or the symptoms must be reported by me to the attendance coordinator by emailing:
If COVID-19 symptoms and/or elevated temperature are reported to the attendance coordinator, the student who experience the fever and/or the symptoms, must receive a doctor’s clearance in writing before returning to school.
• COVID-19 symptoms check list to be completed every day by parents/guardians of the student before the student comes to school.
• Has the student been around anyone else who was ill? Yes _____ No _____
• Is the student experiencing any of the following symptoms?
o Fever Yes _____ No _____
o Current temperature _________
o Cough Yes _____ No _____
o If yes, for how long _________
o Shortness of breath Yes _____ No _____
o Sore throat Yes _____ No _____
o Chills Yes _____ No _____
o Muscle aches and/or pain Yes _____ No _____
o Headache Yes _____ No _____
o New loss of taste or smell Yes _____ No _____
o Abdominal pain, nausea, vomiting or diarrhea Yes _____ No _____
o Has the student been diagnosed with COVID-19 in the past 3 weeks or do you have a reason to believe the student has COVID-19? Yes _____ No _____
• All parents of students must report a diagnosis of COVID-19 among a household member of the student to the attendance coordinator by emailing:
who will notify the Principal.
• If the student has been exposed to a household member with the COVID-19 diagnosis, that exposed student must stay home from school for 14 days.
• All absences must be reported as usual according to the handbook.
I agree I must report a diagnosis of COVID-19 among a household member to the attendance coordinator by emailing
. If I have been exposed to a household member with COVID-19 diagnosis, I agree I must stay home from school for 14 days and I must report my absence as usual according to the handbook.
1. I understand the risk to have contact with individuals, who have been exposed to and/or have been diagnosed with one or more communicable diseases, including but not limited to coronavirus disease 2019 (hereinafter “COVID-19”) or other medical conditions, diseases, or maladies does exist, and, despite School’s good faith implementation of the Department of Education’s recommended health, hygiene, and social distancing best practices, it is impossible to eliminate the risk that I may be exposed to and/or become infected through contact with or close proximity with an individual with a communicable disease. Risk from contracting such communicable disease might include, illness, permanent disability, or death.
2. I understand, COVID-19 is a new disease and there is limited information regarding risk factors for severe disease. Based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19.
Based on Center for Disease Control (hereinafter “CDC”) guidance, those at high-risk for severe illness from COVID-19 are: people 65 years and older; people who live in a nursing home or long-term facility.
Those at severe risk also include people of all ages with underlying medical conditions, particularly if not well controlled, including, but not limited to: chronic lung disease or moderate to severe asthma; serious heart conditions; those who are immunocompromised (many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications); severe obesity (body mass index [BMI] of 40 or higher); diabetes; chronic kidney disease undergoing dialysis; and, liver disease.
3. I understand by signing below I acknowledge that I do not have an underlying medical condition, as referenced herein, or that if I have such underlying medical condition that the undersigned will first obtain written permission from a licensed healthcare professional prior to attending or participating in School or School Activities, which written approval will be provided to School in advance of attendance or participation.
4. I understand people with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19: cough; shortness of breath or difficulty breathing; fever of 100.3 degrees Fahrenheit or above; chills; muscle pain; sore throat; new loss of taste or smell. This list is not all possible symptoms. Other less common symptoms have been reported, including gastrointestinal symptoms like nausea, vomiting, or diarrhea.
5. I understand ALL students and faculty and volunteers are required to follow social distancing protocols and wear a face mask and/or a face shield.
6. I will not attend School Activities and I will notify School officials if I currently have symptoms or have been in contact with anyone with a confirmed COVID-19 diagnosis in the last 14 days.
7. If I have been diagnosed with COVID-19, I will not attend or participate in School Activities until I have received written medical approval from a licensed health care professional, which approval will be provided to School prior to my attendance.
8. I will not attend or participate in School Activities if they are subject to state or federal government directed quarantine or isolation.
9. I understand the School retains the right to deny the student’s attendance or participation in School Activities, if School determines that such attendance or participation is an undue health risk to staff, students, or others. School similarly has the right to deny any other individual from attending School Activities if said individual’s attendance poses an undue health risk to that individual or others.
pk Student Initials
Parent or Guardian Initials
10. THE UNDERSIGNED KNOWINGLY AND FREELY ASSUMES ALL SUCH RISKS for my attendance or participation in School Activities. 11. The undersigned agrees that the undersigned will comply with any safety or health related rules, terms, or conditions for participation in School or School Activities. After fully and carefully considering all the potential risks involved, I hereby assume the same and agree to release and hold-harmless Assumption Catholic School and its employees, officers, agents, contractors, vendors (“School”), the Parish, the Diocese of Metuchen, the Bishop of the Diocese of Metuchen and all its employees, officers and agents from and against, all claims and liability resulting from exposure to disease-causing organisms and objects, such as COVID-19, associated with F/S/V participating in School Activities, to include, but not limited to educational, co-curricular, or extracurricular programs.
Signature of Parent or Legal Guardian *Type the parent's name as a legal signature.
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