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Student Health Check In Form
Please complete the following Student Health Check In Form for EACH student NO LATER THAN 7:30 a.m. each day. Thank you!
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* Indicates required question
Student's Homeroom class
*
Choose
Mrs. Liz Muncy
Mrs. Tina Sowders
Mrs. Susan Swiderek
Mrs. Gina Simmons
Mrs. Erin Kolpacke
Mrs. Carie Bellamy
Ms. Samantha Vendittelli
Ms. Alexa Deutschmann
Ms. Alex Forster
Mrs. Michelle MacLellan
Mrs. Morgan Detweiler
Mrs. Sarah Button
Mrs. Nancy Christie
Ms. Jessica Swartz
Mrs. Maria MacKenzie
Mrs. Lisa Formosa
Mr. Rob Arnould
Mrs. MaryBeth Nicholas
Ms. Caitlin Pacente
Mrs. Kore Smith
Mrs. Stacy Werner
Mrs. Kim Cinzori
Mrs. Micki Shore
Mr. Russ Facione
Mr. Tom Riley
Mrs. Barb Zahari
Mrs. Colleen Kalisieski
Mr. Andrew Willing
Mrs. Amy Roose
Mrs. Amy Blanchette
Student LAST Name
*
Your answer
Student FIRST Name
*
Your answer
Is your student currently experiencing ANY ONE of the following symptoms? 1. Fever (100.4 degrees or greater, 2. New Cough; 3. Shortness of Breath; 4. Difficulty Breathing; 5. Loss of Taste or Smell;
*
Yes
No
Is your student currently experiencing ANY TWO or MORE of the following symptoms? 1. Chills; 2. Diarrhea (2xs in 24 Hrs); 3. Congestion or Runny Nose; 4.Nausea or Vomiting (2x in 24 hrs); 5. Headache; 6. Muscle Aches; 7. Sore Throat; 8. Fatigue
*
Yes
No
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