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* 1. Student's First Name?

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* 2. Student's Last Name

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* 3. Your First Name?

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* 4. Your Last Name?

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* 5. Is your child experiencing ANY of the following symptoms? (New Cough, Shortness of Breath, Difficulty Breathing, New Loss of Smell, New Loss of Taste)

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* 6. Is your child experiencing ANY of the following symptoms? (Fever, Chills, Muscle Aches, Headaches, Sore Throat, Nausea or Vomiting, Diarrhea, Fatigue, Congestion or Runny Nose)

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* 7. Does your child have temperature over 100.4?

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* 8. Is your child taking reducing fever medications in order to reduce fever?

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* 9. Has your child traveled outside Illinois or outside of the U.S. in the last 14 days?

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* 10. Is your child or anyone within the household under quarantine by a healthcare provider or local health department?

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* 11. In the past 2 weeks, has your child been in contact with someone who has tested positive for COVID-19?

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* 12. I confirm the answers above are valid and true.

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