Child's Name *

First Name

Last Name

Before students are permitted to join their class, parents/guardians are required to answer this COVID-19 questionnaire: *

My child hasn't tested positive through a diagnostic test for COVID-19 in the past 5 days.

My child hasn't been in close or proximate contact in the past 5 days with anyone who has tested positive through a diagnostic test of COVID-19 or who has or had symptoms of COVID-19.

My child has not traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 5 days.

Before students are permitted to join their class, parents/guardians are required to confirm that the student has not experienced any symptoms of COVID-19 in the past 5 days, including the following: *

My child hasn't had a fever (temperature over 100.4° F or 38° C) without having taken any fever-reducing medications in the past 5 days?

My child hasn't experienced a loss of smell or taste in the past 5 days?

My child hasn't had a cough in the past 5 days?

My child hasn't experienced muscle aches in the past 5 days?

My child hasn't had a sore throat in the past 5 days?

My child hasn't had congestion or a runny nose in the past 5 days?

My child hasn't had shortness of breath in the past 5 days?

My child hasn't experienced any gastrointestinal symptoms such as nausea, vomiting, diarrhea, or loss of appetite in the past 5 days?