Health Screener | Dear World Academy

Covid-19 Health Declaration

How are you and your Children/Ward feeling today?

First Name

Last Name

My and my child/ward body temperature is lower than 100.5°F

I and my child/ward have not had at least 2 of the following: Chills, Shivers, Muscle Aches, Headache, Sore Throat, Nausea/Vomiting, Diarrhea, Fatigue, Congestion/Runny Nose in the last 24 hours?

I and my child/ward have not had any of the following: Cough, Shortness of Breath, Difficulty Breathing, New Loss of Taste or Smell in the last 24 hours?

I and my child/ward have not had close contact (within 6 feet for at least 5 minutes) with a person with confirmed COVID19 in the Past 14 Days?

I and my child/ward have not had close contact (within 6 feet for at least 5 minutes) and do not have somone in my household that has symptoms of COVID-19, is currently waiting for COVID-19 test results (excluding standard testing), or is diagnosed with COVID-19?

I and my child/ward have not been to an Area of High Community Transmission (see NJ Travel Advisory)?

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!