MCS (Freedom) 21-22 Health Attestation Form

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This form is required to be completed daily for all students in order to attend Movement School in-person. Please answer each question honestly in order to keep our scholars and staff safe.

Email *

today's date *

YYYY

Student Name (First and last) *

Grade Level *

Kindegarden

1ST

2ND

3RD

4TH

5TH

Has your scholar been tested and had a positive result or have you been told by a healthcare provider that you are likely positive for COVID-19? *

Yes

Within the last 14 days has your scholar been in close contact with anyone that you know has been diagnosed with COVID-19 or has had COVID-19 related symptoms? *

yes

Does your scholar have one or more of the following symptoms? *

shortness of breath or difficulty breathing

chills

severe headache

diarrhea

loss of taste or smell

sore throat

cough

muscle aches

None of the above

Required

Contact number for follow up by school nurse or administration if required *

I consent that I have answered each question to the best of my knowledge and I will exclude my scholar from in-person learning if they have tested positive for Covid-19, been exposed for more than 15 minutes, or shows one or more of the symptoms listed above (insert parent name) *

A copy of your responses will be emailed to the address you provided.

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