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School Attestation Form


RCS School Attestation Form

Please complete this school attestation form for any child attending an RCS school. Families will need to submit one attestation form for each child within their family. Please complete this and return the form to your child’s school prior to attending school in-person for the 2020-2021 school year. Please print to complete this form. Thank you!

Child’s First and Last Name: ____________________________________________________________________________

School and Grade: ________________________________________ Student Date of Birth (DOB):_____________________

Parent/Guardian First and Last Name:______________________________________________________________________

1. Has your child had close contact (within 6 feet for at least 15 minutes) in the last 14 days with someone diagnosed with COVID-19, or has any health department or health care provider been in contact with you and advised you to quarantine?

○ If yes, the child should not be at school. The child can return 14 days after the last time they have had close contact with someone with COVID-19.

○ If no, the child can be at school if they are not experiencing symptoms.

2. Does your child have any of these symptoms?

○ Fever

○ Chills

○ Shortness of breath or difficulty breathing

○ New Cough

○ New loss of taste or smell

**If a child has any of these symptoms, they should go home, stay away from other people, and the family member should call their health care provider.

3. Since they were last at school, has your child been diagnosed with COVID-19?

○ YES

○ NO

*If a child is diagnosed with COVID-19 based on a test, their symptoms or does not get a COVID-19 test but has had symptoms, they should not be at school and should stay at home until they meet the criteria below.

Returning to School

A child can return to school when a family member can ensure that they can answer YES to ALL three questions:

● Has it been at least 10 days since the child first had symptoms?

● Has it been at least 24 hours since the child had a fever (without using fever reducing medicine)?

● Has there been symptoms improvement, including cough and shortness of breath?

If a child has had a negative COVID-19 test, they can return to school once there is no fever with the use of fever- reducing medicine and they have felt well for 24 hours.

If a child has been diagnosed with COVID-19 but does not have symptoms, they should remain out of school until 10 days past their first positive COVID-19 diagnostic test, assuring they have not subsequently developed symptoms since their last positive test.

If a child has been determined to have been in close contact with someone diagnosed with COVID-19, they should remain out of school for 14 days since the last known contact unless they test positive. In which case, criteria above would apply. They must complete the full 14 days of quarantine even if they test negative.

A child can return to school, following normal school policies. If they receive confirmation of an alternative diagnosis from a health care provider that would explain the COVID-19- like symptom(s), once there is no fever without the use of fever reducing medicines and they have felt well for 24 hours.

If any of these symptoms listed above develop at school, I understand that my child will need to be picked up immediately from school. I attest that the following information is true to the best of my knowledge and I will report any change immediately to my child’s school:

Signature: _______________________________________ Date: ________________________


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Leaksville-Spray Elementary School

415 Highland Drive

Eden, NC 27288

Phone: 336-627-7068

Fax: 336-627-8823

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Rockingham County Schools

511 Harrington Highway

Eden, North Carolina 27288

Phone:  (336) 627-2600  Fax:  (336) 627-2660

Superintendent's E-mail:  rshotwell@rock.k12.nc.us

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