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Anointed Scholars Inc.

11030 S Longwood Dr, Chicago IL 60643

Phone:312-798-9046

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Covid-19 Health Declaration

This form must be completed before attending our program

How are you feeling today?

Child First & Last Name

Parent/Guardian First & Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing these symptoms: fever, cough, sore throat, trouble breathing

I haven’t been in close contact with a Covid-19 patient/person in the last 14 days

Initials

Date

I declare that the info I’ve provided is accurate & complete

I agree to the terms & conditions as it applies to Anointed Scholars Inc. Policy and Procedures

Thanks for submitting!

Anointed Scholars Inc.

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