2. Please fill out this form when your teen may want to enter the center on non-registered days.
4. Parent Phone Number*
6. Parent Email Address*
8. Teen's Name*
10. Is your child a Biddeford Resident or Biddeford High School Student?*

    1. Biddeford High School Student
    2. Biddeford Resident
    3. Neither
12. Has your child been diagnosed with COVID-19 in the past 28 days?

    1. Yes
    2. No
14. Does your child live with someone who has been diagnosed with COVID-19 or is symptomatic in the past 14 days?

    1. Yes
    2. No
16. Does your child have any of the following symptoms that are explained or different from known health conditions?

    1. Fever (100° or higher)
    2. Chills/repeated shaking with chills
    3. Sore throat
    4. Difficulty breathing/shortness of breath
    5. Unexplained muscle aches
    6. New cough
    7. New loss of smell or taste
    8. New nasal congestion
    9. Vomiting or diarrhea in last 24 hours
18. Is the Teen Center staff permitted to take forehead temperature?

    1. Yes
    2. No
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

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