2021-2022 One-Time Attestation

Because COVID-19 continues to be a concern for our communities, and we recognize the range of symptoms each individual may experience if they contract the virus, we ask each family/caregiver to take personal responsibility by signing this one-time required form, and agree to follow appropriate steps before sending your child to school for the 2021-2022 calendar year.

By signing this, you will agree to support our COVID-19 Pandemic Recovery and Safety Plans. This attestation will help a lot to ensure everyone in the TLC community remain safe and healthy. Thank you!

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By signing this attestation, I am confirming the following:

Child's Name:*

First NameLast Name

Parent/Guardian Name:*

First NameLast Name

Today or in the past 24 hours, my child has not, nor any household members have not, had any of the following symptoms:

Fever (temperature of 100.0°F or above), felt feverish, or had chills
Cough
Sore throat
Difficulty breathing
Gastrointestinal symptoms (diarrhea, nausea, vomiting)
Fatigue
Headache
New loss of smell/taste
New muscle aches
Any other signs of illness

My child, nor any household members, have not had any of the aforementioned symptoms in the past 24 hours.*

This statement is true.No, this is not true.

In the past 14 days, my child has not had close contact with a person known to be infected with the novel coronavirus (COVID-19).*

This statement is true.No, this is not true.

In the past 14 days, my child has not traveled outside of the designated Low Risk* States*

This statement is true.No, this is not true.

*Travel advisories within the United States may shift at any time due to COVID-19 recommendations. Should there be a designated list of Low and High Risk states, identified by the Commonwealth of Massachusetts, it will be found here.

I have not given my child medicine to lower a fever.*

This statement is true.No, this is not true.

Parent/Guardian Signature

2021-2022 Student Attestation