Annual Self-Certification Commitment Form- COVID-19 Mitigation |
As we prepare to start the 2021-2022 school year, we are asking parents/guardians to provide an annual self-certification commitment, which is part of the District’s overall COVID-19 mitigation strategy. The documents associated with our mitigation strategy are available for review by going to:
Please complete and submit this form for each of your students.
By my acknowledgement below, I agree to the following:
I will assess my student(s) for the following COVID-19 symptoms prior to each school day:
-Fatigue from an unknown cause
-Muscle or body aches from an unknown cause
-New cough
-Shortness of breath or difficulty breathing
-New congestion or runny nose
-Fever (100.4 or higher)
-New onset of moderate to severe headache
-New loss of sense of taste or smell
-Vomiting
-Nausea
-Diarrhea
-Abdominal pain from an unknown cause
-Shortness of breath
-Sore throat
If my student (vaccinated or unvaccinated) exhibits any of the symptoms listed which are inconsistent with seasonal allergies or other chronic conditions affecting my student, I agree to keep my student home from school or school activities. I further agree that I will contact the school if my student is exhibiting any of these symptoms and will speak with the school nurse or my building administrator prior to sending my student back to school.
I further agree to inform the school if a member of our household has been exposed to or is diagnosed with COVID-19, and to consult with the school nurse or my building administrator prior to sending my student to school. I understand that I should not send my student to school if they have been directed to quarantine by my health care provider or local department of health.
By my acknowledgement below, I agree to the following:
I will assess my student(s) for the following COVID-19 symptoms prior to each school day:
-Fatigue from an unknown cause
-Muscle or body aches from an unknown cause
-New cough
-Shortness of breath or difficulty breathing
-New congestion or runny nose
-Fever (100.4 or higher)
-New onset of moderate to severe headache
-New loss of sense of taste or smell
-Vomiting
-Nausea
-Diarrhea
-Abdominal pain from an unknown cause
-Shortness of breath
-Sore throat
If my student (vaccinated or unvaccinated) exhibits any of the symptoms listed which are inconsistent with seasonal allergies or other chronic conditions affecting my student, I agree to keep my student home from school or school activities. I further agree that I will contact the school if my student is exhibiting any of these symptoms and will speak with the school nurse or my building administrator prior to sending my student back to school.
I further agree to inform the school if a member of our household has been exposed to or is diagnosed with COVID-19, and to consult with the school nurse or my building administrator prior to sending my student to school. I understand that I should not send my student to school if they have been directed to quarantine by my health care provider or local department of health.