Daily Health Form

By signing my child in today, I attest that today and in the past 24 hours, neither my child NOR any household member have experienced any of the following symptoms

Fever (temp of 100F or above)
Cough / sore throat
Rapid breathing or difficulty breathing (without recent physical activities)
New loss of taste or smell
Gastrointestinal distress (nausea, vomiting, diarrhea)
New muscle aches
Flushed cheeks
Headache
Runny nose or congestion
Fatigue (when accompanied by another symptom)
Any other signs of illness
Been in contact with someone ill with a respiratory illness
Been in close contact with someone confirmed / presumed COVID-19 within 14 days
Has traveled to a COVID-19 high risk state
Awaiting COVID-19 test results

Child(ren)'s First Name

Child(ren)'s Last Name

Sign-in Date

Signature

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!