COVID-19 ENGLISH FORM | Little Kings & Queen

This form is mandatory for entry into Little Kings & Queens Daycare and must be filled out DAILY in its entirety

Covid-19 Health Declaration

How are you feeling today?

Child's First Name

Child's Last Name

Contact Number

I declare that my child/myself has not had any of the following symptoms in the past 14 days: Fever, runny nose, vomiting, cough, shortness of breath, sore throat, chills, loss of taste or smell. I also declare that no one in my household has had these symptoms in the past 14 days.

I declare my child/myself has not had direct contact with someone that tested positive for COVID-19 in the past 14 days?

I delclare my child/myself has not been diagnosed with COVID-19 in the past 14 days?

I declare my child/myself has not traveled in the past 14 days?

I declare that my child/myself has been practicing social distancing and wearing a mask outside of my home for the past 14 days.

I declare that the info I’ve provided is accurate & complete.

Date

Thanks for submitting!