Miscoe Hill Middle School Annual Health Information 2021-2022

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

Dear Parent/Guardian.

Please complete the information on this form and provide your electronic signature as requested. It is important that the school have up-to-date information to meet the needs of your child in the event of an emergency. All information will be kept confidential according to Massachusetts State Law. If you have any questions, feel free to call the health office at 508-634-1589. This form will be sent directly to the Nurse at Miscoe Hill School.

Email *

Student's Last Name *

Student's First Name *

Student's Grade *

COVID-19 Certification *

By checking this box, I am certifying that each day I send my child to school they have been free of COVID-19 symptoms (see symptom list below) for the past 24 hours. I am also certifying that my child has not been asked to quarantine or isolate by a public health official and that to my knowledge, they have not been in close contact with anyone who has tested positive for or has been experiencing COVID-19 symptoms.I will notify the school nurse any time my child travels to a high risk state for greater than 24 hours.

Required

COVID-19 Symptoms

❏ Fever (100.4° Fahrenheit or higher), chills, or shaking chills
❏ Cough (not due to other known cause, such as chronic cough)
❏ Difficulty breathing or shortness of breath
❏ New loss of taste or smell
❏ Sore throat
❏ Headache when in combination with other symptoms
❏ Muscle aches or body aches
❏ Nausea, vomiting, or diarrhea
❏ Fatigue, when in combination with other symptoms
❏ Nasal congestion or runny nose (not due to other known causes, such as allergies) when in combination with other symptoms

Clear form

Never submit passwords through Google Forms.

This form was created inside of Mendon Upton Regional School District. Report Abuse

Forms