2020-21 Health Statement הצהרת בריאות

Health Statement הצהרת בריאות

2020-21
Parent Name *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
How many children are you bringing to Peula today? *
1st Child's Name *

First Name Last Name
1st Child's Grade
2nd Child's Name *

First Name Last Name
2nd Child's Grade
3rd Child's Name *

First Name Last Name
3rd Child's Grade
4th Child's Name *

First Name Last Name
4th Child's Grade
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 14 days? *

Yes No
Has your child been in contact with anyone while they had COVID-19 or symptoms of COVID-19 in the past 14 days? *

Yes No
Has your child traveled outside of state of Nevada in the past 14 days? *

Yes No
In the past 14 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: