Our Lady of Mercy Health Screening Annual Form
Please complete and submit this form BEFORE attending Religious Education classes this year. In case of COVID-19 exposure please call the Religious Education Office at 201-391-3590. As part of the Back to School Religious Education process, parents/guardians will be required to attest that they agree to perform the health screenings prior to bringing his/her child to religious education class by digitally signing below.
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SECTION 1: Symptoms- As per the New Jersey Department of Health, any of the symptoms below could indicate a COVID-19 infection in children and may put your child at risk for spreading illness to others. Please note that this list does not include all possible symptoms and children with COVID-19 may experience any, all, or none of these symptoms. Please check your child before attending a religious education class for these symptoms. Students who are sick (e.g. fever, vomiting, diarrhea) should not attend religious education in-person. If your child is exhibiting at least one of the following symptom(s) keep your child home and notify your health care provider for further instruction. Fever, unusual fatigue, chills, congestion or runny nose, muscle aches, cough, headache, sore throat, difficulty breathing, loss of smell or taste, nausea or vomiting. *
Required
SECTION 2: Close Contact/Potential Exposure: I agree to keep my child home from Religious Education classes if he / she has had close contact (within 6 feet of an infected person for 15 or more minutes during a 24-hour period) with a person with COVID-19, if someone in your household is diagnosed with or being tested for COVID-19 or if your child has traveled internationally. *
Required
Family LAST Name *
Child(ren) Name(s) and Grade(s) *
Parent Name *
Parent Email *
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