Parent/Guardian Name

First Name

Last Name

Student Name

First Name

Last Name

Travel

Has your child has traveled out of the state or country in the last 14 days?

Exposure

As far as you know, has your child has been exposed to someone who has been diagnosed with COVID 19?

Symptoms

Has your child has experienced some/all of the following symptoms in the last 14 days: temperature over 100.3 or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, rash, abdominal pain?

Behavior Agreement

I understand that if my child does not follow MAMM's safety measures that he/she will be sent home.

Yes, I understand.

Notes