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COVID-19 FORM


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COVID-19 Reopening Screening Form-Parents and Children

This Screening Waiver is intended to increase the precautions necessary to protect everyone in our Circle of Care from the COVID-19 virus and minimize the risk of spread. Please complete the following form and return it to any instructor before child’s start date. 


Name: ______________________________________ Age: __________ Date: _________________ 

Child’s Name: ________________________________ Email: _______________________________ 


  1. Do you currently have a fever of 100.4 F or greater? 

____Yes ____No 

  1. Does your child currently have a fever of 100.4 F or greater? 

____Yes ____No 

  1. Are you currently experiencing any respiratory illnesses such as a cough, sore throat, or shortness of breath? 

____Yes ____No 

  1. Is your child currently experiencing any respiratory illnesses such as a cough, sore throat, or shortness of breath? 

____Yes ____No 

  1. Have you or your child had contact with anyone diagnosed with COVID-19 in the last 14 days? 

____Yes ____No 

  1. Have you or your child experienced any of these symptoms in the last 14 days: cough, sore throat, fever greater than 100.4 F, shortness of breath?

____Yes ____No 

∙ If you have answered “Yes” to any of the questions above, you and your child will be excluded from coming into the center for a period of 14 days or otherwise notified. 

∙ Please notify us immediately by PHONE if any of the above answers change. 


Parent Signature: ________________________________________ Date: _________________


ĉ
Amatos Karate,
Jul 7, 2020, 2:37 PM
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