FOMU YA IDHINI YA MZAZI KWA KUPIMWA COVID-19 KATIKA KIKUNDI

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Andika Jina ya Mzazi/Mlezi: *

Rununu/Simu ya #Mzazi/Mlezi: *

Baruapepe ya Mzazi/Mlezi: *

Jina la kwanza la mwanafunzi *

Jina la familia ya Mwanafunzi *

Address Line 1 *

Address Line 2

City *

Zipcode *

Tarehe ya Kuzaliwa: *

(MM/DD/YYYY)

YYYY

Gender *

Female

Male

Transgender

Race *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian and Other Pacific Islander

White

Other Race

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Kitambulisho cha Mwanafunzi # *

Hii ni Nambari ya LASID au ya Chakula cha Mchana. Ni nambari ya tarakimu 6 ambayo huanza na # 2 (mfano: 293456). Wanafunzi hutumia kuingia kwenye kompyuta.

Shule *

Darasa: *

Darasa

(if applicable)

Je mtoto aliyeorodheshwa hapa juu ametambuliwa kuwa na maradhi ya COVID-19 katika siku 90 zilizopita?: *

Ndiyo

Hapana

IDHINI *

Ninakubali

Saini ya Mzazi/ Mlezi: *

Tafadhali andika jina lako

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