Child's Name *

First Name

Last Name

1. In the last 72 hours, have you, your child or anyone at home had any of these symptoms? *

• Fever or chills

• Cough

• Shortness of breath or difficulty breathing

• Fatigue

• Muscle or body aches

• Headache

• New loss of taste or smell

• Sore throat

• Congestion

• Nausea or vomiting

• Diarrhea

• Seems sick or like they are starting to get sick

NONE OF THE ABOVE - REQUIRED FOR ENTRY

2. Within the last 14 days have you, your child or anyone at home been diagnosed with COVID-19, had a positive test, or been exposed to anyone with the virus? *

No

3. Any traveling out of the state or out of the country in the past 14 days? *

No