Student COVID-19 Form

Student Information
Student ID# (Lunch Number):    


Student First Name:  


Student Last Name:  
Student Date of Birth (mm/dd/yyyy):  


Student Home Campus:  
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Student Grade:  
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Student Address (Include City Zip):  


Guardian Full Name:  


Guardian Cell Number:  
Student COIVD Information
Does your child have symptoms of Covid-19: 
select
 

Start date of Symptoms or Exposure date:   

Has student been fully vaccinated?: 
select
 

Was student diagnosed with COVID-19 in past?: 
select
 

Date of Positive COVID-19 Test?:   

Last date student was on campus/school activity?:   

Location student received COVID-19 Test?:   

Upload a copy of positive COVID-19 test: (Allowed file types .pdf, .jpeg, .jpg)