COVID Form

COVID Formelleeyedesign2021-04-22T17:31:12-07:00

Please Fill Out Daily Form before attending Bridgeway House School

Student / Client Name*
First Last
Contact Email*
Contact Phone
Have you or anyone in your household been in contact with anyone with COVID in the past 10 days?*
Have you left the state in the past 10 days? (Fully vaccinated don't have to self-quarantine)*
Do you have a fever or any symptoms of COVID? Cough, Fever, etc.*
Date*
Month
Day
Year
Student's Temperature*
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