2020-21 Health Statement הצהרת בריאות

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) *
Name 1 *

First Name Last Name
Group 1 *
School 1 *
Name 2 *

First Name Last Name
Group 2 *
School 2 *
Name 3 *

First Name Last Name
Group 3 *
School 3 *
Name 4 *

First Name Last Name
Group 4 *
School 4 *
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 *

Clear
DateTime *
Should be Empty: