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Parent First Name

Parent Last Name

Phone

Child First Name

Child Last Name

+ Add additional child

+ Remove child 2

Child First Name 2

Child Last Name 2

+ Add additional child

+ Remove child 3

Child First Name 3

Child Last Name 3

I affirm that neither my child nor I, nor any other immediate family member, has experienced fever (temperature above 100.4 F) in the last 72 hours.

I affirm that neither my child nor I, nor any other immediate family member, has experienced any signs of illness, including but not limited to runny nose, cough, sore throat, shortness of breath, chills, rash, etc. in the last 72 hours

I agree that neither my child nor I, nor any other immediate family member, has had contact with anyone with a suspected or confirmed COVID-19 case in the last 14 days.

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