PARENT/GUARDIAN Vaccine Attestation Form

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Please use this form to voluntarily share your vaccine status, if you will be driving River Valley Charter School students to school programming.

**RVCS GUIDELINES AND PROTOCOLS FOR CHAPERONES AND DRIVERS

All drivers must wear properly-fitting masks and windows should be open to the fullest extent possible while students are in the vehicle.

Drivers may NOT drive if they have been around COVID-19 positive individuals in the last two weeks, or if they have any of the following symptoms:

*Fever (100.0 F or higher), chills, shaking chills
*Difficulty breathing or shortness of breath
*New loss of taste or smell
*Muscle aches or body aches
*Vomiting or diarrhea (school policy)
*Cough (not due to other known cause, such as chronic cough)
*Sore throat
*Nausea
*Headache
*Fatigue
*Nasal congestion or runny nose

Last Name:

First Name:

Class for whom you are driving/may drive

Mary/Morgan

Brooke/Nell

Karen P/Deb

Rebecca/Jessica

Melanie/Susie

Jane/Melissa

Ali/Lee

Karen F/Jen

Kristin/Andrew

Dave/Eva

Middle School

Other:

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By typing my name below, I certify that I have been fully vaccinated against COVID-19. Full vaccination means it has been two weeks since receiving both doses of either the Pfizer or Moderna vaccine, or after the single dose of the Johnson & Johnson vaccine. *

By typing my name below, I agree to comply with RVCS' COVID-19 guidelines and protocols while driving/chaperoning. *

Today's Date:

YYYY

Is there anything else you would like to share?

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