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COVID Health Acknowledgment Form: Week of June 7

Complete a separate COVID Health Acknowledgement Form for each child in your family or staff member who will be on-campus.This form must be completed prior to arrival for drop-off at the beginning of each school week. Children and staff will not be able to begin drop-off procedure unless this form has been completed prior to arrival.


You must take your child's temperature each day prior to drop-off (if you are a staff member, you must take your own temperature). If the answers to any of the questions on this form changes over the course of the week, the director of the preschool, Ann Robertson, 757-622-3239, must be immediately notified. 


After answering all of the questions, click "Submit Survey" at the bottom of this form. The form will be reviewed by Ann Robertson who will contact you should there be any concerns.

* What is your name?
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* What is your child's name? (If you are a staff member, write "N/A")
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* Check the COVID-19 symptoms for which you have screened. (If you are a staff member, please answer for yourself):
* Has your child had 2 or more of the above symptoms of COVID-19 in the past 14 days? (If you are a staff member, please answer for yourself)
* Indicate by check mark if you, your child, or anyone in your household, including caregivers, has:
* Have you, your child, or anyone in your household, including caregivers, traveled out of state in the past 14 days? If so, please provide more information regarding your travels as it relates to possible COVID-19 exposure.
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* Will you immediately notify the director of the preschool, Ann Robertson, 757-622-3239, if after attending preschool your child develops 2 or more symptoms of COVID-19? Also, will you help your child to avoid contact with others and seek medical attention? (If you are a staff member, please answer these questions for yourself.)