Date

MM

DD

YYYY

Child's Name *

First Name

Last Name

Does your child currently have any symptoms of COVID-19, such as: *

fever.

a new or a changed chronic cough.

a sore throat that is not related to a known or a pre-existing condition.

a sore throat that is not related to a known or a pre-existing condition.

nasal congestion that is not related to a known or a pre-existing condition.

shortness of breath that is not related to a known or a pre-existing condition.

no, my child is not currently experiencing any symptoms.

In the last 14 days, has your child *

travelled internationally?

had close contact with a person who has a probable or confirmed case of COVID-19?

none of the above