*
Required
COVID-19 Reporting Form
ONLY complete this form if your child has received a confirmed positive COVID-19 test result from a medical professional. Ms. Amanda Faucheux, our school nurse, will contact you within 24 hours to discuss procedures for when your child can safely return to school.
Student First Name
*
required
Student Last Name
*
required
Grade
*
required
Birth Date
*
required
(mm/dd/yyyy)
Parent First Name
*
required
Parent Last Name
*
required
Parent Phone Number
*
required
Parent Email
*
required
Is your child involved in any extracurricular activities?*
Yes
No
List extracurricular activity(ies)
Date of Positive Test
(dd/mm/yyyy)
Test Performed
Please Select…
PCR
Antigen
Unknown
Last Date Attended School
*
required
(mm/dd/yyyy)
Has your child experience COVID-19 Symptoms?
Yes
No
1st Day of Symptoms (if applicable)
(mm/dd/yyyy)
Symptoms (check all that apply)*
Fever or chills
Cough
Shortness of breath or difficulty breathing
New loss of taste or smell
Muscle/body aches
Headache
Fatigue
Runny nose or congestion
Sore throat
Nausea or vomitting
Other
Please send a confirmation email to the address below*: