Brave Arts Medcheck form

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Please complete this health screening form for each child you are dropping off at Brave Arts Monday-Friday. If you answer YES to any of the symptom questions below please keep your child home. If your child will NOT be attending Brave Arts due to other illness, COVID symptoms or exposure please contact Sarah at 508-314-1792 prior to 9:00 AM.

Child's First and Last Name *

Is your Brave Arts participant experiencing any of the following symptoms: *

Fever (above 100 degrees)

Cough (unrelated to seasonal allergies)

Runny nose (unrelated to seasonal allergies)

Shortness of breath

Sore throat (unrelated to seasonal allergies or vocal fatigue)

Unusual or unexplained headache

Unusual or unexplained fatigue

Chills or body aches

Vomiting or diarrhea

Naseau

Loss of smell or taste

Abdominal pain

None of the above

Required

In the last 14 days has your child been in close contact with anyone diagnosed with COVID-19 OR (if unvaccinated) been placed on quarantine for possible contact with COVID-19? *

Yes

In the past 14 days, has your child been asked to self-isolate or quarantine by a medical professional or public health official? *

Yes

If your child is experiencing any of the listed symptoms or has been notified to isolate or quarantine due to confirmed exposure please do not come to Brave Arts and call Sarah to discuss at 508-314-1792 as soon as possible.

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