Health Screening

Admission Pre-visit Health Screening Form

Required

Please complete this form in its entirety prior to your campus visit. The form must be completed individually for each member in your party.

Must contain a date in M/D/YYYY format
I am asymptomatic of any illness (cough, fever, sore throat, etc.)required
Is your temperature under 100 degrees?required

Have you:

In the past 24 hours: (Check all that apply)requiredPlease select up to 5 choices
Please select up to 5 choices
In the past 48 hours:requiredHave you or anyone in your household had a COVID test?​
Have you or anyone in your household had a COVID test?​
Are you fully vaccinated against Coved-19?required
Electronic Signatrerequired
By selecting yes under Electronic Signature, I am indicating my signature. I am also agreeing that the information above is true, and I will adhere to the Country Day visitor policy.