What is your name?
What is your e-mail address?
What is your family password?
Name of faculty/student Temperature °F Used fever reducing medication in the past 24 hours Yes No Two or more Category 1 Symptoms Yes No One or more Category 2 Symptoms Yes No Close Contact in the past 10 days Yes No
Has anyone in the house tested positive for COVID-19 in the last 10 days or is anyone awaiting a COVID-19 test result? Yes No
The Goddard School of Millburn 161 Millburn Ave, Millburn, NJ 07041 973-671-4500 • MillburnNJ@goddardschools.com
