Student Name *

If you have two children attending please use the notes section for your second child. You do not need to submit a second form.

First Name

Last Name

Date of Absence

Please indicate the first date your child will be absent. If this is for an ongoing illness, please put today's date (or the next day if filling out in the evening)

MM

DD

YYYY

Return Date

Use this field for planned absences. Please leave this blank if this is an ongoing illness and you do not know for sure what day your child will be back.

MM

DD

YYYY

Symptoms, if sick *

Please Check All That Apply

my child is not sick

Fever or Chills - 100.4 degrees or higher

Cough

Nasal Congestion or Runny Nose

Shortness of Breath or Difficulty Breathing that is not part of a diagnosed heath condition

Chills

Sore Throat

Ear Ache

Muscle Aches with an unknown cause

Fatigue, including "not acting like themselves"

Headache

Loss of Taste or Smell

Abdominal Pain, Diarrhea, Nausea, or Vomiting

Poor Appetite or Poor Feeding

Rash

other

If sick, please provide the date of the onset of symptoms

MM

DD

YYYY

Date of COVID test

MM

DD

YYYY