2020-21 Daily Student Health Screen Agreement

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The health and well being of children and families at MJP are of paramount importance to us. In an effort to prevent COVID-19 from entering our facility, please complete and submit the below health screening questions each day before bringing your child to school.Only one form needs to be filled out per family. Please be sure to list names of all children attending.

If your child, or any immediate family members living in your home, show any of these symptoms, your child will not be admitted to school. Please call Rivkie @ 262.242.5437 or email rspalter.mjp@gmail.com to let the school know.

Child(ren)'s Last Name *

Child(ren)'s First Name(s) *

Class

Infant/Toddler

Please list any special instructions or information you would like to share with your child's teacher today.

Our family has not traveled in the last 10 days* *

True

False

My child/ren does/do not currently have, nor has had a temperature over 100 degrees in the past 48 hours *

True

False

My child/ren does/do not currently have, nor has had, potential symptoms of COVID-19, such as shortness of breath or persistent dry cough in the past 48 hours *

True

False

My child/ren hashave not been given medications to lower his or her temperature. *

True

False

There is no one in our household who has COVID-19 *

True

False

By typing my name and date below, I acknowledge that all statements above are true. *

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