Daily At-Home Self Evaluation Screening Agreement For Jackson Parents/Guardians

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Please read the document below and answer the questions that follow.

Student's First Name *

Student's Last Name *

Student's Grade *

Student's ID# (same as computer login) *

I have read the at-home self evaluation agreement. I understand that it is my responsibility to conduct the at-home self assessment every day before sending my child to school, and agree to keep my child home if he/she is experiencing any symptoms. Please check to indicate you agree. *

I agree

Parent's Name (Typing your name in the space below denotes your signature.) *

Parent's Phone Number *

Date *

YYYY

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