Seoul International School Orange Pass

Who is it for *
Name *

First Name Last Name

What Grade *
Which Department *
Current Temperature *
Select Your Current Temperature
Phone Number *
XXX-XXXX-XXXX
Date

Year Month Day

I am free of the following COVID-19 symptoms :

1. Do not have any COVID-19 symptoms.
- Sore throat
- Coughing
- Difficulty breathing
- Chills
- Muscle ache
- Headache
- Loss of smell and taste
2. No one in my household is under quarantine or showing COVID-19 symptoms

3. None of my family members have been overseas in the past 14 days
*

Yes No

I agree that the school collects my information!

The school will collect
- Name
- Contact Number
until KCDC announces COVID-19 pandemic is over.

I certify that all the information and answers to questions are complete, true and correct.
Signature *

Clear
Parent Signature *

Clear
Guest Signature *

Clear
Should be Empty: