Lessons with Jason LIlly Parent/Guardian Name * First Name Last Name Student Name * First Name Last Name Travel * Has your child traveled out of the state or country in the last 14 days? No Yes Exposure * As far as you know, has your child been exposed to someone who has been diagnosed with COVID 19? No Yes Symptoms Has your child experienced some/all of the following symptoms in the last 14 days: temperature over 100.3 or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, rash, abdominal pain? No Yes Behavior Agreement * I understand that if my child does not follow MAMM's safety measures that he/she will be sent home. Yes, I understand Notes Thank you!
