GBM Daily COVID-19 Screening Form
Please complete all questions, selecting an answer for each item. 

This form must be submitted DAILY within two hours of your child's admittance. 

If it has not been received, your child is unable to attend school that day. 

Thank you for working with us to keep our community healthy!
Child's Full Name *
Temperature in *F *
Time Temperature Taken *
Time
:
Has your child experienced a fever, cough, sore throat, diarrhea, loss of taste/smell and/or had difficulty breathing in the past 14 days? *
Has any member of your household experienced a fever, cough, sore throat, diarrhea, loss of taste/smell and/or had difficulty breathing in the past 14 days? *
When you took your child's temperature within the last 2 hours, was it 100.3 *F or higher? *
Has your child or a member of your household traveled by airplane, bus, or train within the past 14 days? *
Has your child or a member of your household traveled outside of Michigan or the USA within the past 14 days? *
Has your child or a member of your household been in close contact (within 6 ft for 15 min) with a person who has been confirmed or waiting on COVID-19 test results within the past 14 days? *
Has your child or a member of your household been instructed to self-quarantine within the past 14 days by a healthcare provider? *
By submitting this form, I am agreeing that the above information is accurate. In consideration for accepting my child, I herby agree to indemnify, defend and hold harmless Grand Blanc Montessori and its employees of any liabilty, claim or demand arising out of or related to COVID-19 or other communicable diseases or conditions. I am assuming such risk. Please enter your full name below. *
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