Health Screening

First name*

Last name*

Date of confirmed campus visit*

Location visiting*

Hillsdale/Red Bank campus
Doherty campus

Email*

Mobile phone*

List the names of the members of your group*

Appointment time*

:

Name of Seven Hills employee contact for meeting*

Are you fully vaccinated against COVID-19?*

Yes
No

Add any comments regarding the vaccination question here.

Do you or anyone in your party have any of these symptoms?*

Fever or chills (without fever reducing medication)
Cough (without cough suppressants)
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
Recent loss of taste or smell
Sore throat
Congestion
Nausea or vomiting
Diarrhea

Yes
No

COVID-19 Contact*

Within the past 10 days, have you had contact with anyone that you know had COVID-19 or COVID-like symptoms?

Yes
No

COVID-19 Testing*

Have you had a positive COVID-19 test in the past 10 days?

Yes
No

Hidden

Self-monitor*

Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection?

Yes
No

If the answer is yes for you or any member of your group, to any of the questions above, please contact Seven Hills to reschedule the appointment.

Visitor Policy Acknowledgement*

I/we agree to the visitor policy.

By checking yes, I am indicating my signature. I confirm that neither I nor any individual in our group responded in the affirmative to the conditions above. I/we will follow the guidelines of the Seven Hills School visitor policy.

Student Visit Day

Will a student be on campus for a Middle or Upper School student visit (shadow) day?*

Yes
No

Parent/Guardian Name*

Phone #1*

Phone #2

Secondary emergency contact*

Secondary Phone #1*

Secondary Phone #2

Please note any medical information for our nurse, including allergies, medications, physical limitations, etc and special instructions*

Emergency contact acknowledgement*

I/we consent emergency medical treatment for my student

By checking above, in the event that I cannot be contacted, I hereby consent to emergency medical treatment, hospitalization, or other treatment as may be necessary for the welfare of my child by a physician, qualified nurse, or hospital and its personnel in the event of injury or illness during the period of time when my child is visiting The Seven Hills School. I also consent to emergency use of my child's Epi-pen (to be provided by the parent if needed) by a faculty member trained in the use of an Epi-pen, in the event that my child shows signs of an allergic reaction.

Health Screening/Emergency Contact Information

Student Visit Day