COVID-19 RELEASE FORM
In accordance with interim guidance from the New York State Department of Health, all children are required to complete this questionnaire prior to entry. Thank you for your cooperation.
Today's Date
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Month
-
Day
Year
Child's name
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First Name
Last Name
Has your child knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19?
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Yes
No
Has your child tested positive for COVID-19 in the past 14 days?
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Yes
No
Has your child experienced any symptoms of COVID-19 in the past 14 days? Symptoms of COVID-19 include, but are not limited to: cough, shortness of breath or difficulty breathing, fever,chills, muscle pain, sore throat, or new loss of taste or smell.
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Yes
No
Submit
Should be Empty: