ChildFirst

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ChildFirst

ChildMiddle

ChildLast

Child's Name

October 9, 2024 at 7:50:45 PM

Submission Date

Health Assessment Form

Contact's First Name

In case of an emergency, please complete the info below:

Contact's Middle Name

Contact's Last Name

Relationship To Student

Home Phone

Cell Phone

Authorization

I give permission for my child to participate in San Francisco Achievers in-person activities.

Child's First Name

Child's Middle Name

Child's Last Name

Signature

Are you fully vaccinated?

Yes

Has your student left the state of California within the last 30-days?

Yes

Has anyone in your home been diagnosed with the Coronavirus?

No

Has your child had a fever now or in the last two weeks?

No

Has your child been hospitalized within the last two weeks?

No

Has your child had contact with anyone outside of your household?

No

Text Message Ok?

No

Choose Primary Phone

Cell

Special Instructions

Test2

Please expand on any Yes answers from above:

Test2

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