HSA Form for In-Person Religious School

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Please fill this out completely on Thursdays before 3:00 pm and Sunday mornings before 9:30 am if you are coming in person to Beth El for Religious School. Temperatures will still be taken upon arrival.

Please arrive at Beth El and line up in your car for us to check you in at least 15 minutes before the beginning of class (that would be 9:45 am on Sundays that you are scheduled and 3:45 pm on Thursdays that you're scheduled).

You'll need to fill this form out each day you come in person for each of your children joining.

Questions? Contact Stephanie Lederman: slederman@bethelnr.org.

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Effective 11/3/2020

Every individual entering Beth El Synagogue Center for any reason will be required to attest to the absence of symptoms of COVID. These include but are not limited to:
o Fever (T>100F or chills)
o Cough and/or shortness of breath
o Sore throat
o Weakness, fatigue, muscle aches
o Loss of taste or smell
o Nasal congestion and/or runny nose
o Nausea, vomiting and/or diarrhea
o Rash

Every individual entering the building will also have to attest that they have not recently (within less than 14 days) been exposed to anyone (a) displaying symptoms of or (b) having tested positive for COVID infection. An exposure is defined as having been within six feet of the person for 10 minutes or more or coming into contact with fluids from this person (such as a cough or sneeze) with or without a mask.
Every individual entering the building will attest to the fact that
(1) they HAVE NOT traveled outside NY (other than to CT, NJ, MA, VT, or PA) for greater than 24 hours in the past 14 days
OR
(2) they HAVE traveled outside NY (other than to CT, NJ, MA, VT, or PA) for greater than 24 hours in the past 14 days but
(a) they quarantined for 14-days
OR
(b) they tested COVID Negative less than 3 days before leaving that location, quarantined for 3 days, and then tested COVID Negative in New York

Email *

Child's Name (First and Last) *

Child's Religious School Grade

Gan/Kitah Alef (K/1st Grade)

Kitah Bet (2nd Grade)

Kitah Gimel (3rd Grade)

Kitah Dalet (4th Grade)

Kitah Hey (5th Grade)

Kitah Vav (6th Grade)

Gesher (7th Grade)

Teen Learning (8th-10th Grade)

Educators

Other:

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Date you are attending Religious School in-person at Beth El *

Today's Date

YYYY

In the past 24 hours, have you had:

Please select all that apply

Fever (T>100F or chills)?

Cough and/or shortness of breath?

Sore throat?

Weakness, fatigue, muscle aches?

Loss of taste or smell?

Nasal congestion and/or runny nose?

Nausea, vomiting and/or diarrhea

Rash?

A general sense of not feeling well?

None of the Above

In the past 14 days, have you:

Please select all that apply. To access the CDC's most up-to-date travel ban list, please click here: https://coronavirus.health.ny.gov/covid-19-travel-advisory

Had any of the symptoms listed above?

Tested positive for COVID-19?

Had close contact with someone who has COVID-19 or symptoms?

Travelled to any states on the travel ban or out of the country?

None of the Above

Please write your name (parent name if parent is filling this out) to acknowledge that this information is correct.

Please write the best person to contact and their phone number today in case of emergency.

Send me a copy of my responses.

Submit

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