CMS Covid-19 Acknowledgement Form
Acknowledgement of Risk

I understand there is a risk of infection from the Coronavirus to myself (my child) by participation in activities with other students and staff, and by a presence in school environments despite disease prevention measures put in place by Culpeper County Public Schools.
Please enter the student athlete's full name (including middle). This will serve as an e-signature for acknowledgement. *
Please enter the parent's full name (including middle). This will serve as an e-signature for acknowledgement. *
Acknowledgement of Responsibility
I understand it is my responsibility to promote the health of myself (or of my child) and others by following the guidance and
directions from school staff to practice proper hygiene practices and disease prevention measures. Participation in school
activities is considered a privilege and may be suspended or revoked if my actions (or those of my child) are deemed to be in
violation of these practices and measures. Furthermore, I have read the CCPS Coronavirus (COVID-19) Mitigation Plan and
will adhere to its requirements.
Please enter the student athlete's full name (including middle). This will serve as an e-signature for acknowledgement. *
Please enter the parent's full name (including middle). This will serve as an e-signature for acknowledgement. *
Submit
Never submit passwords through Google Forms.
This form was created inside of Culpeper County Public Schools. Report Abuse