Dear Parent/Guardian,

To ensure the health and safety of your child and others, please complete and sign this card and give to your young person to turn in for religious education today.

This form is mandated to be filled out by the PARENT every time the child is sent to our monthly in person session. It can be completed prior or upon student arrival, but MUST be completed within 12 hours of class time.

Does my child currently have a temperature of 100.4°F or above?

Does my child have any of these symptoms of COVID-19?
- Fever of 100.4°F or higher
- Cough
- Chills
- Shortness of breath/difficulty breathing
- Loss of taste or smell
- Congestion/runny nose
- Nausea/vomiting/diarrhea
- Muscle/body aches
- Fatigue
- Sore throat
- Headache

Has your child knowingly been near someone who in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19?

Has your child tested positive for COVID-19 in the past 14 days?

Has your child traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days?