This form is to be used when students are returning to the school setting after any absence.

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1. Student Name:

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2. Class:

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3. Parents/Guardian’s Name:

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4. School/Setting Name

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5. Declaration:
I have no reason to believe that my child has infectious disease and I have followed all medical and public health guidance with respect to exclusion of my child from educational facilities.

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6. Signed:

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7. Date

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