Blast Check In

1

Date* This field is required.

Date

2

Number of children checking in* This field is required.

3

First Child's Name:* This field is required.

First Name

Last Name

4

First Child's Grade Level* This field is required.

5

Second Child's Name:* This field is required.

First Name

Last Name

6

Second Child's Grade Level:* This field is required.

7

Third Child's Name:* This field is required.

First Name

Last Name

8

Third Child's Grade Level:* This field is required.

9

Fourth Child's Name:* This field is required.

First Name

Last Name

10

Fourth Child's Grade Level:* This field is required.

11

Fifth Child's Name:* This field is required.

First Name

Last Name

12

Fifth Child's Grade Level:* This field is required.

13

Sixth Child's Name:* This field is required.

First Name

Last Name

14

Sixth Child's Grade Level:* This field is required.

15

Does anyone in the household have any of the following symptoms?* This field is required.

New and persistent cough

Shortness of breath or any difficulty breathing

Fever

Lost of taste or smell

Sore throat

No symptoms

16

Has anyone in your household been tested for COVID-19 in the past 14 says and still awaiting test results?* This field is required.

YESNO

17

Have you recently (preceding 14 days) been in close contact with anyone who has lab confirmed positive for COVID-19?

YESNO

18

Has anyone in your household been tested for COVID-19 in the past 14 days and still awaiting test results?

YESNO

19

Emergency Phone Number* This field is required.Please provide a cell phone number that we may call or text during our services.

20

Parent/Guardian Name:* This field is required.

First Name

Last Name

21

Signature:* This field is required.