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Cheryl Woodsom

Owner/Operator 978-317-3920

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Daily Health Attestation

This form must be filled out EVERY DAY that your child attends

Childs Name

Dropping off Parents Name

Has the child or anybody in your household exhibited the symptoms below in the past 24 hours?

Fever (100F or higher) or had chills? *

No

Yes

Cough? *

No

Yes

Sore Throat? *

No

Yes

Difficulty Breathing? *

No

Yes

Nausea, vomiting or diarrhea? *

No

Yes

Loss of Taste or Smell? *

No

Yes

Muscle Aches? *

No

Yes

If your child has the following symptoms not in combination with any of the above, they are approved to attend.

Fatigue
Head Ache
Runny Nose or Congestion

Has the child or another houshold member had close contact with a Covid-19 Positive individual in the past 14 days? *

No

Yes

Drop off Date

Drop off Time

Your Signature

Thanks for submitting!

If you answered yes to any of the above questions your child may not attend today. Please contact me for more information.

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