CTR Kids Health Attestation Form

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This form should be completed by the adult who will be attending CTR Kids with their child(ren). If your child is 6 or older and will be attending CTR Kids without an adult, either parent/guardian may complete this form as long as the adult will be at church on Sunday.

**Please complete a separate form for EACH child who will be attending CTR Kids.**

Parent/Guardian Name *

Parent/Guardian Cell Phone Number *

Child Name *

Child Age *

Will your child attend CTR Kids with an adult? (Only children ages 6 and up may attend without an adult.) *

YES, I will attend CTR Kids with my child.

NO, my child will attend CTR Kids without an adult (ages 6 and up only).

Have you or your child had close contact with a COVID-19 positive individual within the last 14 days? (If you answered "yes," we ask that you not attend in-person church this Sunday and join us virtually instead.) *

YES

Have any of the following symptoms been observed in your child or a household member in the past 24 hours? (If you answer "yes," we ask that you not attend in-person church this Sunday and join us virtually instead. Per childcare guidelines, fatigue, headache, runny nose/congestion, and other signs of illness not listed are not cause for exclusion unless combined with another symptom. In this case, please use your discretion, and if necessary, err on the side of caution.) *

Fever (100 or higher), feverish, chills

Cough

Sore throat

Difficulty breathing

Gastrointestinal distress (nausea, vomiting, or diarrhea)

New loss of taste or smell

New muscle aches

Fatigue (*must be in combination with other symptoms to be cause for exclusion*)

Headache (*must be in combination with other symptoms to be cause for exclusion*)

Runny nose or congestion (*must be in combination with other symptoms to be cause for exclusion*)

Any other signs of illness (*must be in combination with other symptoms to be cause for exclusion*)

NO, no member of my household is exhibiting any of the above symptoms.

Required

Additional Information

For children attending CTR Kids without an adult (ages 6 and up only), you may either walk downstairs with them or they can meet me (Ms. Kara) at the back of the sanctuary when the families are dismissed after announcements. I will escort them back upstairs prior to communion. Thank you!

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