Child's Name *

First Name

Last Name

Date *

MM

DD

YYYY

Child's Birthday

MM

DD

YYYY

Does your child have any medical problems (including, but not limited to, any of the following: asthma, chronic pulmonary disease, diabetes, cancer - in treatment or in remission, or any condition past or present that requires any steroid or immunosuppressive medications)?

YES

NO

Does your child have a fever or above normal temperature (above 99.4 degrees)? *

YES

NO

Has your child had a fever in the past 14 days? *

YES

NO

Has your child experienced shortness of breath or had trouble breathing? *

YES

NO

Does your child have a dry cough? *

YES

NO

Does your child have a sore throat? *

YES

NO

Does your child have a runny nose? *

YES

NO

Does your child have recent onset diarrhea? *

YES

NO

Has your child recently lost or had a reduction in their sense of smell or taste? *

YES

NO

Have you or your child tested positive for COVID-19? *

YES

NO

Have you, your child or anyone in your household been in contact with anyone who has tested positive for COVID-19? *

YES

NO

Has anyone in your household been tested for COVID-19 and are awaiting results? *

YES

NO

Have you or anyone in your household traveled anywhere within or outside of the United States by air, bus, train or cruise ship in the past month? *

YES

NO

Is anyone in your household a critical or essential worker? *

YES

NO