Name: *

First Name

Last Name

Date Absent:

MM

DD

YYYY

Date Returned:

MM

DD

YYYY

I verify that I have been free of any of the following symptoms for at least 24 hours prior to returning to school. *

• Fever or chills • Shortness of breath or difficulty breathing • Unusual muscle or body aches • Cough • Sore throat • Nausea or vomiting • Diarrhea • Congestion or runny nose not due to allergies • Headache

YES

I verify that I have not been in contact with anyone diagnosed with COVID-19 nor have I been notified that I may have been exposed to it. If exposed I have remained at home for two weeks before returning to school, and am free of symptoms. ** *

YES

I verify that I have not traveled to a high risk area, and I have not been involved in any high risk activities. If I traveled to an area of high risk for COVID, I have been quarantined for two weeks prior to a return to school, and free of any symptoms. ** *

If traveling out of the area, the child must be quarantined for two weeks prior to a return to school, and free of any symptoms.

YES

Confirm Info

By submitting this form I attest to this information being accurate and complete.