Minor Covid-19 Release Form

Students Name*

First Last

Has the child been in close contact with a confirmed case of COVID-19 in the past 14 days?*

Is the child experiencing a cough, shortness of breath, or soar throat?*

Has the child had a fever of 100.5 or higher in the past 24 hours.*

Has the child had a new loss of taste or smell?*

Has the child had any vomiting or any diarrhea in the last 24 hours?*

Take the child's temperature on the date indicated below and enter it the box.*

Parent/Guardian's Name*

First Last

Phone Number*

Date*

Signatre*

By checking this box I agree that all information was completed truthfully to the best of my ability.