Back-to-School Health Declaration Form

Have parents confirm a student's recent travel, exposure, and symptom history before returning to campus, with a signed acknowledgment.

Use this template

Parent/Guardian Name

Nombre

Apellido

Email

Student Name

Nombre

Apellido

Student ID

Class

Have you visited other countries or cities in the past 21 days?

Yes No

Have you had contact with anyone confirmed or suspected of having COVID-19 in the past 21 days?

Yes No

Symptom list: fever, cough, shortness of breath, loss of taste or smell, sore throat

Is the student experiencing any of the symptoms listed above today, or has experienced any within the last 24 hours?

Yes No

I, the undersigned, agree with the following statements:

I confirm the information provided is true and complete

Date

Signature

Sign here

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