COVID-19 Pandemic Health Screening and Waiver of Liability

I affirm that:

  1. Neither I, my student, nor anyone in my household (We) has any symptoms of COVID-19, to include: fever, chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea.  **Symptoms taken from  the CDC website
  2. We have not had any of the above symptoms of COVID-19 during the last 14 days.
  3. We have been exercising 6 feet social distancing and avoiding gatherings of 11 people or more.
  4. We have not traveled away from the DMV geographical area.
  5. I understand that if we have traveled out of the DMV geographical area my child must not attend school for 14 days upon return, or until results of a negative COVID-19 test are provided to the office
  6. To my knowledge we have not been exposed to anyone with COVID-19 symptoms in the last 14 days. (Refer to item #1)
  7. I have not given my student fever reducing medicine in the last 24 hours.
  8. I understand that during my student’s attendance at St. Stephen’s UMC Preschool they may be exposed to the COVID-19 virus or the risk of such exposure, which may be lowered but not eliminated. The risk and hazard of COVID-19 may include, but are not limited to, the dangers of serious illness and death.
  9. I acknowledge that it is my responsibility to assess our own risk factors and to make a decision regarding whether I can safely send my student to St. Stephen’s UMC Preschool.
  10. I understand the inherent risks of transmission of COVID-19 during this global pandemic and I am waiving and releasing St. Stephen’s UMC Church and Preschool from liability.
  11. I will immediately notify St. Stephen’s Preschool administration of any symptoms (refer to item #1), illnesses, and diagnosis of COVID-19.

REVISED 1/28/2021


Student's Name

Affirmation *