My child (ren) does (do) not have any of these symptoms *

Please check any applicable box(es)

Fever over 38 c

New or persistent cough

Shortness of breath

Sore throat

Chills

Flu-like symptoms

Conjunctivitis (pink eye)

Vomiting, nausea or diarrhea

Runny nose/nasal congestion

Painful swallowing

Travel Quarantine Mandates

I verify that if I, my child (if applicable) and any members of my household have returned to NY from any country outside of US or states which requires 14 days of quarantine mandate, we will notify Queens Music Academy.

Yes, I will

Student (s)'s Name(s) *

First Name

Last Name

Parent(s)'s name(s) *

First Name

Last Name