Visitor Health Screening for Moving Up Ceremony

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Guests of students should complete this screening on the morning of Thursday, June 24 before to 9 a.m.

Email *

Child's Last Name *

Child's First Name *

Your Last Name *

Your First Name *

Phone Number (xxx) xxx-xxxx *

Have you tested positive for COVID-19 in the past 10 days? *

Yes

Have you had close contact with someone with a confirmed positive COVID-19 test in the past 10 days? *

Yes

I have either tested positive for COVID-19 and have recovered or I have been fully immunized for at least two weeks

Do you currently have any of the following symptoms: chills, congestion or runny nose, cough, sore throat, fatigue, headache, muscle or body aches, shortness of breath or difficulty breathing, new loss of taste or smell, nausea or vomiting, diarrhea? *

Yes

Have you had a fever (100 degrees F or greater) in the past 24 hours? *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Pelham Union Free School District. Report Abuse

Forms