Child's Name (required)
[text* Child's Name (first & last)]

1. Is your child's temperature higher than or equal to 100.0 degrees Fahrenheit? (required)
[text* Child's Name (first & last)] YesNo

2.Has your child had any known contact with a person confirmed or suspected to have COVID-19 in the past 14 days?(required)
[text* Child's Name (first & last)] YesNo

3. Is your child currently exhibiting ANY of the following symptoms: • Cough (new or worsening)
• Shortness of breath (new or worsening)" "• Trouble breathing(new or worsening)" "• Fever" "• Chills" "• Muscle pain (new or worsening)" "• Headache (new or worsening)" "• Sore throat (new or worsening)" "• New loss of taste" "• New loss of smell" ""(required)
[text* Child's Name (first & last)] YesNo

1. Is your child's temperature higher than or equal to 100.0 degrees Fahrenheit?2. Have you had any known contact with a person Confirmed or suspected to have COVID-19 inthe past 14 days?3. Are you currently exhibiting ANY of the □ □ ● Cough (new or worsening)• Shortness of breath (new or worsening)• Trouble breathing(new or worsening)• Fever• Chills• Muscle pain (new or worsening)• Headache (new or worsening)• Sore throat (new or worsening)• New loss of taste• New loss of smell4. Have you tested positive through a diagnostic test □ □In the past 14 days?5. Have you had any recent international travel or travel to an area requiring a 14 day quarantine upon return?(See posted states for reference)6. Have you had a COVID-19 antibody test? (optional)

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