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Daily Health Attestation
Complete this form each morning before arrival. We will verbally confirm with you that it has been completed when you drop off.
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* Indicates required question
Use the check boxes to indicate if today, or in the past 24 hours, you or any of your household members have had any of the following symptoms (Note - if you answer “yes” your child may not attend the program):
*
Fever (100.0 or above); felt feverish
Cough
Sore Throat
Difficulty Breathing
Gastrointestinal Symptoms
Abdominal Pain
Unexplained Rash
Headache
New Loss of Taste or Smell
New Muscle Aches
Any other sign of illness
NONE/NO SYMPTOMS
Required
In the past 10 days have you or anyone in your household had close contact with a person known to be infected with the novel coronavirus? If you answer YES: The CDC now says that you now must quarantine for 10 days after exposure, or only 7 if you have a negative COVID test.
*
Yes
No
In the past 10 days have you or anyone in your household traveled to any of the higher risk states as determined by the Commonwealth of Massachusetts?
*
Yes
No
Enter your children(s) full name(s)
*
Your answer
Enter today's date
*
MM
/
DD
/
YYYY
By entering your full name below, you attest that the answers to this survey are complete and accurate to the best of your knowledge.
*
Your answer
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