Health Screening

Please select your reason for visiting today. *Student drop offEmployeeVolunteerVisitor

Teacher Name *Please select your child's teacherMiss AMiss BMiss C

Miss A's Class *Please select your child's nameChild ZChild YChild X

Miss B's Class *Please select your child's nameChild WChild UChild V

Miss C's Class *Please select your child's nameChild TChild SChild R

Employees *Please select your nameMiss AMiss B Miss C

Your Name *

Volunteer Name *

Visitor Name *

If you–or anyone in your household–are experiencing ANY of the following symptoms, please check the appropriate box.

• Cough (new or worsening)
• Shortness of breath (new or worsening)
• Trouble Breathing (new or worsening)
• Fever
• Chills
• Muscle pain (new or worsening)
• Headache (new or worsening)
• Sore throat (new or worsening)
• New loss of taste
• New loss of smell

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