Child's NameFirst NameLast NameHas your child taken fever reducing medicine today?YesNoHas your child or anyone in the household been in contact with anyone diagnosed with COVID-19 in the past 14 days?YesNoDoes your child or anyone in the household have a cough, shortness of breath, or difficulty breathing?YesNoDoes your child or anyone in the household have any 2 of the following symptoms? Headache, muscle pain, aches, fever, chills with physical shaking, loss of taste, or loss of smellYesNoAny other comments or concerns you would like to let us know?Signed: Parent's NameFirst NameLast NameSubmitShould be Empty: This page uses TLS encryption to keep your data secure.