This form is to be used when students are returning to the school setting after any absence.

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* 1. Student Name:

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* 2. Class:

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* 3. Parents/Guardian’s Name:

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* 4. School/Setting Name

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* 5. Declaration:
I have no reason to believe that my child has infectious disease and I have followed all medical and public health guidance with respect to exclusion of my child from educational facilities.

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* 6. Signed:

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* 7. Date