COVID-19 PARENT-STUDENT-VISITOR-STAFF Screening FORM

This Form is Required to be Filled Out DAILY!

Name*

Email*

Phone:*

Date:*

Time:*

Do you, your child, or a live-in family member have a fever of 100.4?*

Have you, your child, or a live-in family member experiencing shortness of breath within the last 14 days?*

Have you, your child, or a live-in family member experienced a dry cough within the last 14 days?*

Have you, your child, or a live-in family member experienced a runny nose within the last 14 days?*

Have you, your child, or a live-in family member experienced a sore throat within the last 14 days?*

Have you, your child, or a live-in family member experienced any unexplained mucsle pain or headache within the last 14 days?*

Have you, your child, or a live-in family member been in close proximity of someone who has. tested positive for COVID-19 in the past 14 days?*

I agree to notify KidsZone asap if my child becomes ill with symptons or test positive for COVID-19. Print your full name as your electronic signature*

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