Parent or Guardian's Name *

First Name

Last Name

Child's Name *

First Name

Last Name

Child's Name

First Name

Last Name

Have you experienced any symptoms of COVID-19, including a fever of 100.0 degrees F or greater, a new cough, new loss of taste or smell or shortness of breath within the past 10 days?  *

Yes

No

In the past 10 days, have you gotten a positive result from a COVID-19 test that tested saliva or used a nose or throat swab? (not a blood test) *

Yes

No

To the best of your knowledge, in the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone who tested positive for COVID-19 or who has or had symptoms of COVID-19? *

Yes

No

Have you traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days? *

Yes

No

Date *

MM

DD

YYYY