Travel Health Form

The School is committed to taking reasonable measures to ensure the well-being of the whole community, and with your assistance, we can ensure a safe and healthy atmosphere. It is essential that all members of the Maplebrook community do not return to campus with any illness, including such ailments as the common cold. This applies to students, faculty, staff, and their family members who reside on campus. As a precaution, we will be screening all students and staff upon return after spring break and based on temperatures and potential symptoms, we will seek out assistance from Sharon Hospital or ask that students return home to recover where appropriate.

If your son/daughter has any symptoms of a respiratory infection, please do not bring them back to the campus. Students must be fever free without fever reducing medication for 48 hours before returning to campus.

Please complete and submit this health form five days prior to your son/daughter’s return to campus.

STUDENT NAME *

Student is a resident of what country: *

Has the student traveled to another country or to different states while on Spring Break *

YesNo

If you answered yes to the previous question, list all of the countries or states visited:

Has the student had close contact with a person who is ill: *

YesNo

If you answered yes to the previous question, how long ago:

Has the student had any signs of the following symptoms:

Fever / TemperatureCoughShortness of Breath

If you answered yes the any of the symptoms, what was the date of the onset:

We appreciate your cooperation and we will continue
to have the best interest of
your son/daughter's health while on campus.

Form Completed by: *

Date Completed: *

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Nursing assesment

Nurses Initials DateTemperature

The learning that takes place in our athletic program compliments our student-athletes learning in the classroom and prepares them for life after Maplebrook.

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Travel Health Form