Health Questionnaire Fill Out Our Health Questionnaire to Attend Our Classes TNT School Health Questionnaire Registration Please fill out this health Questionnaire 2-3 hours before a class that your child will attend at TNT to confirm health and attendance. TNT School Health Questionnaire Temple Ner Tamid 1. Date to attending TNT classDate MM slash DD slash YYYY 2. Your contact info:Name* First Last Home City/Town State/Province ZIP / Postal Code Email* Phone*3. Please write only the FIRST name of your child who is attending your school. First 4. Does your child now have or in the past 48 hours have had a temperature of 100F or greater?* Yes No 5. Does your child have a cough? (new onset, or worsening in the past 48 hours?)* Yes No 6. Is your child short of breath? (New onset, or worsening in the past 48 hours.)* Yes No 7. Has your child been in direct contact with anyone who has the above symptoms or has been diagnosed with COVID - 19 within the past 14 days?* Yes No 8. Has your child lost a sense of taste or smell?* Yes No 9. Has your child recently developed abdominal pain &/or diarrhea not consistent with a pre existing condition? For example, IBS, Celiac disease...* Yes No 10. My answers are truthful and answered to the best of my ability.* Yes No 11. I understand that If I answered yes to any of questions 4-9, that I need to contact my healthcare provider for medical advice and authorization (in the form of written communication) for my child to return to classes at TNT.. Until such time, my child will not attend classes or enter the TNT building. Alternatively, I will provide proof of a negative Covid-19 test.* Approve Disapprove 12. I understand that my child is expected to wear a mask when in the Synagogue Building - We will not send any food or drink - I understand that my child is not permitted to sing while in the Synagogue. My child has been made aware of the policies and agrees to abide by all Policies and Procedures set forth by TNT* Agree Disagree 13. This form must be filled out 2 to 3 hours before the Class to attend Date MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Δ
