My child does not currently have, nor have they had in the last 48 hours, a temperature over 100 degrees. *

True

False

My child does not currently have Covid-19. *

True

False

My child does not have potential symptoms of Covid-19, such as: Shortness of breath Persistent Dry cough Sore Throat Loss of Taste or Smell Fever Upset stomach; Nausea, Diarrhea, Vomiting Headache *

True

False

I have not given my child medication to reduce his or her fever. *

True

False

There is no one in my household that has Covid-19, or Covid-19 symptoms in the last 14 days. *

True

False

No member of my household has come in close or proximate contact with a confirmed or suspected Covid-19 case in the last 14 days. *

True

False

No member of my household has returned from travel to areas with community spread of Covid-19 as defined by the CDC and NY State Department of Health in the last 14 days. *

True

False

As a family, we have limited the number of people that we have come in contact with and are abiding by the “social contract” with the My Little Village Community to prevent the spread of Covid-19. *

True

False

Child's Name *

First Name

Last Name

Parent's Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY