COVID-19 Daily Health Screening Form [MANDATORY]

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Must be filled out and submitted DAILY by 10AM

Child's Name: *

Today's Date: *

YYYY

NOTE: IF YOU SELECT "YES" TO ANY OF THE FOLLOWING QUESTIONS, YOUR CHILD MAY NOT ATTEND THE PROGRAM UNTIL ALL ANSWERS ARE "NO."

Are you or your child currently experiencing any symptoms of Covid-19? (ie. fever, cough, sore throat, or shortness of breath) *

Yes

Have you or your child taken a Covid-19 test that returned "positive" in the past 14 days? *

Yes

Have you or your child been in close contact with any confirmed or suspected Covid-19 cases in the past 14 days? *

Yes

Have you or your child traveled to any of the states/territories on the NYS "Restricted States" list in the past 14 days? *

The most up to date list of states and territories can be found here: https://coronavirus.health.ny.gov/covid-19-travel-advisory

Yes

NOTE: IF YOU SELECTED "YES" TO ANY OF THE ABOVE QUESTIONS, YOUR CHILD MAY NOT ATTEND THE PROGRAM UNTIL ALL ANSWERS ARE "NO."

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