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Covid Symptom Form
Covid Symptom Form
Please complete the form below. Required fields marked with an asterisk *
Student Name
*
Answer Required
Student Grade Level
*
Answer Required
Please Select
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Please check all symptoms that your child is experiencing:
*
Answer Required
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea, stomach ache or vomiting
Diarrhea
Other
If "Other", please explain:
Answer Required
Do you plan on testing?
*
Answer Required
Please Select
Yes
No
If yes, select the date for the test. Please email results to the CK nurse at
[email protected]
Answer Required
Confirmation Email
Confirmation Email
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