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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.?

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* 4. If yes, please explain.

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* 5. In the past 14 days, has anyone living in your home been in contact with a person who has been diagnosed with COVID-19 or developed symptoms of COVID-19?

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* 6. In the past 14 days, has anyone living in your home traveled from high-risk states as outlined in New York State Executive Order 205?  For states with high risk of COVID-19, please visit the following link: https://coronavirus.health.ny.gov/covid-19-travel-advisory.

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* 7. If yes, please explain.

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* 8. Date you completed this survey

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