(if submitting on your phone, you may need to turn horizontally to view entire answer!) Please enable JavaScript in your browser to complete this form.1. Has your child, or someone in your household experienced any of the following symptoms in the past 14 days: fever (100 F or more), cough, shortness of breath, sore throat, congestion or runny nose? *Choose oneYesNo2. Has your child, or someone in your household experienced any of the following symptoms in the past 14 days: body or muscle ache, extreme fatigue, nausea, diarrhea or vomiting, new loss of taste or smell? *Choose oneYesNo3. Has your child, or someone in your household been diagnosed or tested positive for COVID-19 in the past 14 days? *Choose oneYesNo4. Has your child, or someone in your household knowingly been in close contact with or cared for someone diagnosed or tested positive with COVID-19 within the last 14 days? *Choose oneYesNo5. In the past 14 days, has your child been in close contact with anyone who has traveled to any areas designated by the CDC or to a US State with significant community spread of COVID-19 and listed under a travel advisory by NY State? *Choose oneYesNo6. If you answered YES to any of these questions, has your child since undergone a Covid-19 PCR test and tested negative? (only reply if you've answered YES)Choose oneYesNoParent/Guardian's name *FirstLastChild's Name *FirstLastSubmit
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