Parent/Guardian's Name *

First Name

Last Name

Phone

(###)

###

####

Symptoms *

Do you or your child, or anyone in the household have symptoms of cough (new), fever (above 100.4 Fahrenheit or 38 Celsius), or shortness of breath? If temperature is unknown, one of our staff will use a contactless thermometer to check prior to admittance.

Yes

No

Unknown

Exposure *

Have you or your child been around anyone who has been exposed or diagnosed with COVID-19 in the last 14 days?

Yes

No

Travel *

Have you or your child traveled outside of the country or have been in close contact with someone who has traveled outside of the country?

Yes

No

Date *

MM

DD

YYYY

Time

Hour

Minute

Second

AM PM