Bleckley County Schools Infectious Disease Preparedness Survey

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* 1. Do you have Internet access at home?

Yes

No

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* 2. Do you have a laptop, desktop, or I-Pad?

Yes

No

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* 3. Please provide each student's name and grade level below:

Student #1 Name

Student #1 Grade

Student #1 Cell #

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* 4. Please provide each student's name and grade level below:

Student #2 Name

Student #2 Grade

Student #2 Cell #

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* 5. Please provide each student's name and grade level below:

Student #3 Name

Student #3 Grade

Student #3 Cell #

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* 6. Please provide each student's name and grade level below:

Student #4 Name

Student #4 Grade

Student #4 Cell #

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* 7. Please enter your information below. IMPORTANT: We will use this information to contact you regarding school closing, so please provide accurate information:

Parent Name

Parent Email

Parent Phone Number

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* 8. Please provide any other concerns, suggestions, or additional information that might prove useful:

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* 9. By entering your initials here, you are certifying that the information you have provided is accurate.

Thank you! We appreciate your support as we strive to do what is best for our students!