COVID-19 Disclosure Form

School Update: COVID-19
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COVID-19 Disclosure Form

COVID-19 Disclosure Form
 
Please complete the following disclosure form if one or more of the following apply to your household. PLEASE NOTE: If your child will be absent from school, this form is IN ADDITION to a regular attendance call or email to report your student's absence.
 
1. One or more members of your immediate family and/or co-habitants have had known exposure to COVID-19
2. One or more members of your immediate family and/or co-habitants are exhibiting symptoms of COVID-19
3. One or more members of your immediate family and/or co-habitants have been diagnosed with COVID-19
 
Your form submission will only be seen by administration and will not be shared. 
COVID Disclosure Form
Student name:
Parent/Guardian Name:
I am completing this form because (check all that apply):





Date of symptom onset (if applicable):
Date of Diagnosis (if applicable):
COVID-19 Symptoms Being Exhibited (if applicable; check all that apply):





I/We have read and understand the "Return to School After Illness" checklist and know that our student (if he/she is ill) cannot return to school until all the criteria have been met.
Your Name:
Your Email:

To validate your submission, please answer the following math problem:

captcha math problem
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