Parents Confirmation of Child Wellness
I
Name of parent/guardian
*
, confirms that my child
Name of child
*
(Check all that apply)
*
has had their temperature taken and is Currently Fever Free
has not been given any Fever Reducing Medications in the past 12 hours
does not have a Runny Nose
does not have the Chills
does not have a Cough
does not have Nausea
not Vomiting
does not have Diarrhea
not have Sinus Congestion
does not have Difficult Breathing or Wheezy Breathing
does not have unexplained fatigue, aches or cold/flu like Symptoms
has not been in contact with anyone that may have been Exposed to Covid 19 in the last 14 days the best of my knowledge
has not been Out of the Country in the last 14 days
has not traveled by AIR Internationally in the last 14 days
Signature
Date
/
Month
/
Day
Year
Date
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