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:
select
Early Childhood Center
Carpenter Elementary
Dabbs Elementary
Deepwater Elementary
Deer Park Elementary
Fairmont Elementary
Parkwood Elementary
San Jacinto Elementary
Bonnette Junior High
Deepwater Junior High
Deer Park Junior High
Fairmont Junior High
Deer Park High - North
Deer Park High - South
Deer Park High - Wolters
DAEP
Deer Crossing
Student Grade:
select
Pre-Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Student Address (Include City Zip):
Guardian Full Name:
Guardian Cell Number:
Student COIVD Information
Does your child have symptoms of Covid-19:
select
YES
NO
Start date of Symptoms or Exposure date:
Open the calendar popup.
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Has student been fully vaccinated?:
select
YES
NO
No Answer
Was student diagnosed with COVID-19 in past?:
select
YES
NO
Unsure
Date of Positive COVID-19 Test?:
Open the calendar popup.
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Last date student was on campus/school activity?:
Open the calendar popup.
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Location student received COVID-19 Test?:
Upload a copy of positive COVID-19 test: (Allowed file types .pdf, .jpeg, .jpg)