Wellness Questionnaire
Prior to returning to school back please fill out this form:

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Child Name *
Child's Room *
Sibling? If you answered "No", you may skip the next question. *
If your child has a sibling/s what room are they in?
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Has anyone in your immediate household exhibited any of the following symptoms within the past 5 days: *
Have you been in contact with/social with anyone outside of your immediate household within the past 5 days? *
Has anyone in your immediate household been made aware of an exposure/close contact within the past 5 days? *
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This form was created inside of Little Laurels Montessori Preschool.

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