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Daily Health Assessment and Attestation
Please assess your child each morning for COVID-19 symptoms. Your child may not attend SHACHARIT/MINCHA if any of these symptoms are present or have been present in the past 24 hours. Your child may not attend SHACHARIT/MINCHA if anyone in your household has these symptoms present or if anyone in your household has had close contact with an individual who has tested positive of COVID-19 within the past 14 days.
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Your Child's Name (please submit a form for each child)
Your answer
What time is your child attending SHACHARIT/MINCHA?
Sunday, 11am
Sunday, 4pm
Tuesday, 4:30pm
Other:
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Who is your child's teacher?
Alison Lobron
Becca MacKillop
Beth Rosenblatt
Josh Conescu
Kim Bodemer
Marriah Vengroff
Rachel Groth
Zack Barr
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Within the past 24 hours, did your child or anyone in your household have a fever of 100 degrees or higher, feel feverish, and/or had chills?
Yes
No
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Within the past 24 hours, did your child or anyone in your household have a cough?
Yes
No
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Within the past 24 hours, did your child or anyone in your household have a sore throat?
Yes
No
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Within the past 24 hours, did your child or anyone in your household have difficulty breathing?
Yes
No
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Within the past 24 hours, did your child or anyone in your household have gastrointestinal distress (nausea, vomiting, diarrhea)?
Yes
No
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Within the past 24 hours, did your child or anyone in your household have a new loss of taste or smell?
Yes
No
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Within the past 24 hours, did your child or anyone in your household have new muscle aches?
Yes
No
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Within the past 24 hours, did your child or anyone in your household have fatigue? (This must be in combo with other symptoms to be cause for mandatory exclusion from the program)
Yes
No
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Within the past 24 hours, did your child or anyone in your household have a headache? (This must be in combo with other symptoms to be cause for mandatory exclusion from the program)
Yes
No
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Within the past 24 hours, did your child or anyone in your household have a runny nose or congestion? (This must be in combo with other symptoms to be cause for mandatory exclusion from the program)
Yes
No
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Within the past 24 hours, did your child or anyone in your household had any other signs of illness? (This must be in combo with other symptoms to be cause for mandatory exclusion from the program)
Yes
No
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Within the last 14 days, did your child or anyone in your household have close contact with a COVID-19 positive individual?
Yes
No
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Please state your name here and attest that you have answered the above questions truthfully.
Your answer
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