PSB 2021-22 Student Health Attestation
Dear Parents and Guardians,

School Health staff have collaborated with educators and administrators to plan for our students' full return to school. We will strictly follow guidelines set forth by the Department of Elementary and Secondary Education, in conjunction with our local board of health.

If your child has any medical issues or if you have concerns, we request that you discuss your child’s attendance at school with your healthcare provider. Please also use this form to sign up for free targeted COVID testing. Participation is optional, but your consent is required below. Please complete one form for every child enrolled in PSB.

It is vital that everyone take personal responsibility and do their part to keep our community healthy and safe. We request that you read, review, and sign the agreement below. Please complete this agreement by Friday, September 17. If you or your child feel ill, please stay home. Symptoms of COVID-19 include:

• Fever (100.0° Fahrenheit or higher), chills, or shaking chills
• Difficulty breathing or shortness of breath
• New loss of taste or smell
• Muscle aches or body aches
• Cough (not due to other known cause, such as chronic cough)
• Sore throat, when in combination with other symptoms
• Nausea, vomiting, or diarrhea when in combination with other symptoms
• Headache when in combination with other symptoms
• Fatigue, when in combination with other symptoms
• Nasal congestion or runny nose (not due to other known causes, such as allergies) when in combination with other symptoms.

 Please contact your school nurse if would like a translated version of this form.
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Mobile Phone Number (use formats 123-456-7890) *
Parent/Guardian Last Name *
Parent/Guardian First Name *
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