Student COVID-19 Form

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)