COVID-19 Self-Certification and Verification Form and Guidance for K-12 Students Acknowledgement
Throughout the 2021-2022 school year, the Wilmington School District is again asking all parents and guardians to conduct daily symptom screening prior to their student departing for school each morning. If a child is ill or symptomatic, please refrain from sending him/her to school and notify the building of your child's absence.

We are also asking that all parents carefully read the CDC and Will County Health Department Guidance for K-12 students:

CDC Guidance: https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-guidance.html 

Will County Health Department Guidance: https://drive.google.com/file/d/1AkvOb0YcvZ-aG7GHx72Q4UyybIzV_dMG/view?usp=sharing 

We also wanted to share links to the recent Executive Order from Governor Pritzker regarding the wearing of facemasks, as well as to the Wilmington School District COVID Updates webpage where the full Return to School Plan can found along with other helpful information & updates.

- https://www.illinois.gov/government/executive-orders/executive-order.executive-order-number-18.2021.html

- https://www.wilmington.will.k12.il.us/COVID-19-Updates

At this time, it is important for parents and/or guardians to complete the form below for EACH of our individual students. By submitting this form, you simply will acknowledge that you will participate in the daily symptom screening for each child and that you have read and understood the information from CDC, Will County Health Department, and Governor Pritzker.

If you have not yet been able to access a copy of the full Return to School plan, please contact the District Office or one of our building principals at your earliest convenience.

This form MUST be completed by 4 pm on Monday, August 16th. Please complete a separate form for each student.

Contact Information (to be used to report COVID-19 symptoms and other information) - See Below

Sign in to Google to save your progress. Learn more
Email *
Individual Completing the Form
Email Address
Student's Last Name *
Student's First Name *
School *
Grade Level *
CERTIFICATION and VERIFICATION of DAILY SYMPTOM SCREENING: I verify that prior to utilizing district transportation and/or entering a district building, my student listed below will receive a daily symptom screening at home by an adult caregiver to determine if he/she is experiencing any of the following COVID-19 symptoms: Temperature of 100.4 degrees Fahrenheit (or greater), cough, shortness of breath or difficulty breathing, chills, fatigue, muscle or body aches, headache, sore throat, new loss of taste or smell, congestion or runny nose, nausea and/or vomiting, diarrhea, or any other COVID-19 symptoms as identified by the CDC or IDPH. * *
Required
CERTIFICATION and VERIFICATION of AGREEMENT TO CONTACT THE SCHOOL: If my student is experiencing any of the above symptoms at the time of the daily screening, I will notify the school in writing of my student's absence by sending an email to the building assistant principal and will indicate the symptoms experienced. (Emails provided above) * *
Required
CERTIFICATION and VERIFICATION of OTHER COVID-19 RELATED EXPOSURES: I will notify the school (by emailing the building's assistant principal) that my student will be absent pending further direction from the district if: 1) my student receives a diagnosis of COVID-19; 2) my student is suspected of having COVID-19; 3) my student comes in close contact (definition below) with an individual who tested positive for COVID-19 or is suspected of having COVID-19; or 4) my student traveled internationally. If district staff contacts me to gather further information related to the reason(s) for my student's absence, I will provide the necessary information as requested. For COVID-19, the CDC defines a "close contact" as "someone who was within 6 feet of an infected person (laboratory-confirmed or a clinically compatible illness) for a cumulative total of 15 minutes or more over a 24-hour period (for example, three individual 5-minute exposures for a total of 15 minutes)." * *
Required
CERTIFICATION AND VERIFICATION OF K-12 STUDENT GUIDANCE: I have read and understand both the CDC and Will County Health Department guidance for K-12 students. * *
Required
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Wilmington CUSD 209u. Report Abuse
Google Forms