Emmaus ALC Daily Wellness Check
INSTRUCTIONS:

1. This form must be completed by all ALC Parents prior to physically reporting for drop off.

2. One form is required to be completed EACH DAY per student.

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First Name(s) *
Last Name *
Parent Temperature *
Child Temperature *
Child Temperature (if needed)
Child Temperature (if needed)
Student Health Screening Questions
As of March 20, 2020, the CDC has recommended deaily health screenings of temperature and respiratory symptoms upon arrival each day in many places. Since exposure to COVID-19 is not necessarily a medical condition, questions regarding exposure are permissible as per CDC guidelines. Please answer the Daily Wellness Check Screening Questions below and submit your form prior to drop off each day.
Have you/your child been confirmed positive for COVID-19?
Clear selection
Do you presently have any signs or symptoms of COVID-19 (fever-100.4F or higher, cough, shortness of breath, chills, loss of taste or smell)? *
Clear selection
Have you had any of the above signs or symptoms in the past two weeks?
Clear selection
Have you or your child been in close contact with any person who has been confirmed positive for COVID-19?
Clear selection
If you answer "YES" to ANY of the Student Health Screening questions above, please DO NOT report to ALC and provide details below.
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