RCS BB/BTC - Daily Health Screening Form
Student Daily Screening Form - Parents/Guardians must complete with each student before arrival to the program daily. If you've answered yes to any of these questions, keep your child home and consult with your healthcare provider. Thank you!

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Today's Date *
MM
/
DD
/
YYYY
STUDENT NAME (Last, First) *
STUDENT SCHOOL *
STUDENT GRADE *
PARENT/GUARDIAN NAME (Last, First) Completing this Form *
PARENT/GUARDIAN EMAIL ADDRESS Completing this Form *
COVID-19 Related Symptoms
Within the past 24 hours, has your child experienced any of the following symptoms? *
Required
Has your child experienced any COVID-19 symptoms in the last 14 days? *
Has your child (or anyone in the household) tested positive for COVID-19 in the last 14 days? *
Required
Has your child or a member of the household been tested for COVID-19 due to illness or exposure, and are still awaiting results? *
Required
Has your child traveled to any of the states or places that are currently on the Travel Advisory list in the last 10 days? *
Required
By completing this form, you attest that all information is true to the best of your knowledge. *
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