Required Covid-19 Screening – West Nipissing Child Care Corporation

Please answer the following questions: Check the appropriate box. Thank you.

Does your child have any of the following symptoms: fever, cough, difficulty breathing, muscle aches, fatigue, headache, sore throat, runny nose, or atypical symptoms such as; altered mental status and inattention, falls, abdominal pain, diarrhea, nausea, vomiting, chills, exacerbation of chronic symptoms or croup?*

Yes
No
Not applicable

Within the past 14 days, have you been in direct contact with someone who is experiencing COVID-19 symptoms and self-isolating as a result of it /or with someone with a confirmed case of COVID-19?*

Yes
No

Within the past 14 days have you traveled outside the country or have you been in contact with someone that has been out of the country?*

Yes
No

If you have answered yes to any of the above questions or have refused to answer:

Your child will not be permitted to attend the child care center.

Please indicate which child care your child attends.*

La tanière des tout-petits
Service de garde des louveteaux
La niche des lionceaux
Centre-based
White Woods
La ruche des petites abeilles
EarlyON
Not applicable

Comments

By submitting this form I certify that the above statements are true and valid.

Name*

Date*

Telephone*