Student Information
Student ID# (Lunch Number):
(Numero de almuerzo)
   


Student First Name:
(Primer Nombre)
 


Student Last Name:
(Apellido)
 
Student Date of Birth (mm/dd/yyyy):
(Fecha de nacimiento)
 


Student Home Campus:
(Escuela)
 
select


Student Grade:
(Grado)
 
select
Student Address (Include City Zip):
(Direccion)
 


Guardian Full Name:
(Nobre del Padre/Tutor)
 


Guardian Cell Number:
Numero de celular
 
Student COIVD Information
Does your child have symptoms of Covid-19:
(¿El estudiante tiene sintomas de COVID-19?)
 
select
 

Start date of Symptoms or Exposure date:
(Fecha de inicio de los síntomas)
   

Has student been fully vaccinated?:
(¿El estudiante ha sido vacunado?)
 
select
 

Was student diagnosed with COVID-19 in past?:
(¿El estudiante ha sido diagnosticado con covid en el pasado?)
 
select
 

Date of Positive COVID-19 Test?:
(Fecha de prueba covid positiva)
   

Last date student was on campus/school activity?:
(¿Ultimo dia el estudiante estuvo en el campus?)
   

Location student received COVID-19 Test?:
(¿Ubicación del examen covid?)
   

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