COVID Attestation Form-March

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Monthly Attestation for COVID-19 Screening. By signing this form monthly you agree to perform the following symptom check daily on your student before they leave for school. If your student has ANY of the symptoms listed below they are to stay home and follow the District guidelines.

Student's Last Name: *

Student's First Name: *

School and Grade *

LMS 7th grade

LMS 8th grade

Please check EACH box to show that you have read and agree to check for these symptoms. *

A fever of 100.4 F or higher or a sense of having a fever

A cough

A sore throat

Shortness of breath or difficulty breathing

Chills

New loss of taste or smell

Nausea/vomiting/diarrhea

Congestion/runny nose- not related to season allergies

Unusual fatigue, muscle or body aches

Household members are not displaying signs or symptoms

There has been no contact with anyone with suspected or confirmed COVID-19

Required

Signature- by typing your name you are acknowledging that you have read and agree to check for the above symptoms. If your student has any of these symptoms keep them home and contact the school. *

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