ESHS Student At-Risk Identification Form
(for use during Covid-19)

Elizabeth Seton High School is committed to maintaining a healthy and safe learning and working environment for all of our students and staff. The school administration is closely monitoring the global public health emergency related to Covid-19 through trusted authorities including the Center for Disease Control and Prevention (CDC) and the World Health Organization.

The CDC identified underlying health conditions that place a person at an increased risk for severe illness from COVID-19. A current list of these conditions can be found here: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
Further, children who have medical complexity, who have neurological, genetic, metabolic conditions, or who have congenital heart disease might be at an increased risk for severe illness from COVID-19 compared to other children. Elizabeth Seton High School invites students and staff to voluntarily disclose any underlying health condition in order for the school to proactively consider any reasonable accommodation that may be put in place for its students and staff.

This reporting form is for parents or guardians to notify the school of any underlying medical conditions or concerns related to COVID-19 regarding their daughter. Information that is disclosed in this form will be maintained as confidential and used solely to support a student and her family in the context of the COVID-19 public health emergency. This submission is not a substitute for medical advice. If your daughter experiences any COVID-related symptoms or any medical concerns, please seek medical attention immediately.
Full Name of Student *
Student ID Number *
Date of Birth *
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Parent/Guardian Name *
Parent/Guardian Preferred Phone Number *
Parent/Guardian Preferred Email Address *
Identify the underlying health condition or concerns that may put my daughter at increased risk for severe illness from COVID-19. *
Provide a description of the accommodation(s) you are requesting (for example, an adjustment, change, or other assistance). Please identify a specific accommodation or suggestion(s) if you are not sure. *
We understand it may be obvious, but please describe how the accommodation(s) requested will help your daughter with access to her education or the services provided by the school. *
Please check the Elizabeth Seton High School staff you would like to be notified of this concern: (check as many as appropriate) *
Required
Provide any additional information you think may be relevant to this request. *
FOR OFFICE USE ONLY:
Date Request Received
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Request received by
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