PSB 2020-21 Student Health Attestation (Apr. 2021 Update)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Dear Parents,

School Health staff have collaborated with educators and administrators to plan for our students to attend in-person school in either a full in-person or hybrid model. We will strictly follow guidelines set forth by the Department of Elementary and Secondary Education, in conjunction with our local board of health.

If your child has any medical issues or if you have concerns, we request that you discuss your child’s attendance at school with your healthcare provider.

In response to the updated guidance from the Centers for Disease Control (CDC) and Prevention and the State of Massachusetts, we are asking all staff and families to complete an updated Health Attestation Form by Monday, April 26, 2021. You must complete this form even if you have already filled out the previous Student/Staff Health Agreement in September and November. Please complete one form for every child enrolled in Brookline.

In addition, due to changing guidelines, we request that you refer to MA travel guidelines (https://www.mass.gov/info-details/covid-19-travel-advisory) for any travel plans.

It is vital that everyone take personal responsibility and do their part to keep our community healthy and safe. We request that you read, review, and sign the agreement above. If you or your child feel ill, please stay home

Email *

Student Last Name *

Student First Name *

Student Grade Level *

BEEP

Kindergarten

Student ID Number (LASID)

Student ID Number (LASID) *

This information can be found in your student's Aspen Family Portal.

Student School *

Baker

Driscoll

Heath

Lawrence

Lincoln

Pierce

Ruffin Ridley

Runkle

Brookline High School

BEEP @ Beacon

BEEP @ Clark Road

BEEP @ Lynch

BEEP @ Putterham

I agree to the following: *

My child’s temperature will be checked at home every morning before taking any fever reducing medication. If my child’s temperature is 100 F or 37.8 C or above, I will keep them home from school.

If my child has any symptoms of COVID-19, I will keep them home from school until I have consulted and been cleared by my healthcare provider. Symptoms may include: Fever or chills, Sore Throat, Congestion or Runny Nose (in combination with other symptoms + not due to a previously known condition), Nausea or Vomiting, Diarrhea, Cough (not due to other known causes), Shortness of Breath or Difficulty Breathing, Fatigue (in combination with other symptoms), Muscle or Body Aches, Headache (in combination with other symptoms), New Loss of Taste or Smell

My child will wear a mask to school every day (supplied by family) as able. Masks should be washed or changed daily.

I have shared phone numbers where a responsible adult can be readily reached, at all times.

My child will be picked up from school within 30 minutes of a call from the school nurse that my child is ill. Ill students will be isolated. Space is limited.

I will notify the school nurse if any household member or contact is diagnosed with COVID-19.

I will follow the Massachusetts Emergency Order as issued by Governor Baker. Private gatherings in MA are limited to 10 people indoors and 25 people outdoors. Visit https://www.mass.gov/info-details/covid-19-state-of-emergency for more details.

Required

Parent/Guardian Name *

Please submit your initials to indicate that you have completed the form. *

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Public Schools of Brookline. Report Abuse

Forms