Copy of Student/Family COVID-19 June 9, 2021

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* 1. Please enter your first and last name (person completing this survey). This will serve as your signature that all information is correct.

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* 2. Please enter the name and grade of each of your children attending WCS

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* 3. Is anyone living in your home currently experiencing new or worsening symptoms, such as fever, sore throat, cough, loss of taste or smell, shortness of breath, etc.?

Yes

No

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* 4. If yes, please explain.

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* 5. In the past 10 days, has your child who attends WCS been in contact with a person who has been diagnosed with COVID-19 or developed symptoms of COVID-19?

Yes

No

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* 6. Has everyone living in your home complied with New York State's travel advisory? - please visit the following link: https://coronavirus.health.ny.gov/covid-19-travel-advisory.

Yes

No

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* 7. If no, please explain.

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* 8. Date you completed this survey

Date

Date