Household Isolating Notification Form

Household Isolating Notification Form
Name of Person Completing This Form*

First NameLast Name
Contact Phone Number*

Area CodePhone Number
Contact Email*

Confirmation Emailexample@example.com
Our household is isolating because:*

An adult in the household has tested positive for COVIDA child in the household has tested positive for COVIDOther
Date Household Contact or Child Tested Positive*

DayMonthYear
Date
If Other Please Detail.*
How many children in your household attend Cotswold School?*
Child's Name (1)*

First NameLast Name
Child's Room & Teacher (1)*
Child's Health Status (1)*

Showing No SymptomsWaiting For Test ResultTested Positive for COVIDHad COVID Within 90 Day Period
Date Tested Positive (1)*

DayMonthYear
Date
Child's Name (2)*

First NameLast Name
Child's Room & Teacher (2)*
Child's Health Status (2)*

Showing No SymptomsWaiting For Test ResultTested Positive for COVIDHad COVID Within 90 Day Period
Date Tested Positive (2)

DayMonthYear
Date
Child's Name (3)*

First NameLast Name
Child's Room & Teacher (3)
Child's Health Status (3)

Showing No SymptomsWaiting For Test ResultTested Positive for COVIDHad COVID Within 90 Day Period
Date Tested Positive (3)

DayMonthYear
Date
Child's Name (4)*

First NameLast Name
Child's Room & Teacher (4)*
Child's Health Status (4)*

Showing No SymptomsWaiting For Test ResultTested Positive for COVIDHad COVID Within 90 Day Period
Date Tested Positive (4)

DayMonthYear
Date
Would you like a Home Learning Booklet to support your child's learning at home?*

YesNo
Is a friend or family member not isolating with your family able to collect the Home Learning Booklet from the School Office?*

YesNo
Address For Delivery - Please Note Delivery May Take Some Time and is Dependent On Staff Availability.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Thank you for completing this form.

When you hit the submit button:
- Our Attendance Assistant will update attendance details for your child noting they will be absent for the required isolation period.
  - You will not be required to notify an absence each day.
  - You will however need to notify us of should your child remain at home more than the required isolation period. Please either update this form is use the Hero App to notify and extended isolation period.
- Your child's class teacher will be notified of your child's absence due to the need to isolate.
- If requested we will ensure a Home Learning Booklet is available for pick-up or drop-off.
You will receive a copy of this form emailed to the address you have provided. Please use the EDIT LINK included on the emailed form to update details should circumstances change.

Stay safe and look after yourself and your family.

CHRIS SMITH
Principal
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