Language
English (US)
Hebrew
Health Statement הצהרת בריאות
2020-21
*
I am aware of the change in hours
Parent Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Number of Participants in Activity (Kids, Counselors, Volunteers)
*
1
2
3
4
5
Name 1
*
First Name
Last Name
Group 1
*
3rd-4th
5th
6th
7th
8th
9th
Shachbag
Tzevet
ShinShin
Volunteer
Vaad
School 1
*
Adelson
Desert Torah Academy
Meadows
Yeshiva Day School
Public-Zoom
Parent-No School
Name 2
*
First Name
Last Name
Group 2
*
3rd-4th
5th
6th
7th
8th
9th
Shachbag
Tzevet
ShinShin
Volunteer
Vaad
School 2
*
Adelson
Desert Torah Academy
Meadows
Yeshiva Day School
Public-Zoom
Parent-No School
Name 3
*
First Name
Last Name
Group 3
*
3rd-4th
5th
6th
7th
8th
9th
Shachbag
Tzevet
ShinShin
Volunteer
Vaad
School 3
*
Adelson
Desert Torah Academy
Meadows
Yeshiva Day School
Public-Zoom
Parent-No School
Name 4
*
First Name
Last Name
Group 4
*
3rd-4th
5th
6th
7th
8th
9th
Shachbag
Tzevet
ShinShin
Volunteer
Vaad
School 4
*
Adelson
Desert Torah Academy
Meadows
Yeshiva Day School
Public-Zoom
Parent-No School
Health Declaration
Has your child experienced a fever of 100.4F / 38C or greater in the past 10 days?
*
Yes
No
Has your child received a positive result from COVID-19 test within the past 10 days?
*
Yes
No
Has your child been in contact with anyone while they had COVID-19 or symptoms of COVID-19 in the past 10 days?
*
Yes
No
Has your child traveled outside of state of Nevada in the past 14 days?
*
Yes
No
In the past 10 days has your child experienced any of the following symptoms? Select all that apply
*
Cough
Runny Nose
Loss or reduction in sense of smell
Sore Throat
None of the above
Have you already registered your child to the 2020-21 activity year?
*
Yes
No
COVID-19 Waiver
Covid-19 liability waiver
*
I agree
Signature
*
DateTime
*
Submit
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