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* 1. Name of child(dren) attending CSI

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* 2. Grade(s) of child(dren) attending CSI

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* 3. When CSI reopens in hybrid mode (two days of in-person learning, one day of virtual learning,  and two days of independent learning) will you send your child back into the building?

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* 4. Do you plan on keeping your child in remote instruction (out of the building) for the entire school year?

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* 5. If CSI is required to pivot quickly from the hybrid mode back to full remote instruction, would you be able to secure child care? 

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* 6. If you choose to send your child back into the school building, will your child be taking the school bus? 

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* 7. If you elect to send your child back into the school building, do you understand that your child will be subject to random COVID-19 tests administered by a licensed healthcare worker? 

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* 8. Will you consent to your child receiving random COVID-19 tests by a licensed healthcare worker? 

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* 9. Do you understand that if your child returns to the building that he/she will be required to wear a mask throughout the day, with short breaks when physical distancing can be guaranteed? 

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* 10. Do you understand that when CSI transitions to hybrid learning that your child will be permitted in the building only on his/her assigned days? 

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* 11. Do you understand that students will be required to complete independent work in order to meet New York State Standards and requirements for the minimum number of hours of instruction?

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* 12. Do you understand that your child will not be permitted in the building if he/she is not up to date on all required vaccinations?

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* 13. Do you understand that it is your responsibility to assess your child for illness before leaving for school and not sending your child to school if he/she has a fever, cough, chills, muscle pain, headache, sore throat, new loss of taste or smell, or has been in close contact with someone who tested positive for COVID-19?

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* 14. Do you understand that if your child becomes ill at school, he/she will be put in an isolation room and must be picked up immediately by a responsible adult?

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* 15. Do you understand that during the time of COVID-19, only students and staff will be permitted to enter the building without an appointment? 

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