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Holland Central Schools: Visitor Check-in Form

All visitors must complete the questions below to gain access to the building.

Visitor Name: *

Date Visiting: *

School(s) Visiting: *

Holland Elementary School

Holland Middle School

Holland High School

Bus Garage

Reason for visit, and who you are visiting: *

Have you experienced symptoms of COVID-19 such as fever (temperature of 100°F or above), chills, rigors, muscle aches, headache, back pain, fatigue, runny nose, congestion, sore throat, loss of smell, loss of taste, shortness of breath, difficulty breathing, wheezing, chest pain, cough, abdominal pain, nausea, vomiting, diarrhea, dehydration, altered mental status/confusion, or seizures in the past 10 days? Please answer “yes” only if you are experiencing a new onset of symptoms OR you are experiencing a change in symptoms from your baseline if you have a known preexisting medical condition (e.g. asthma, allergies). *

Yes - You cannot enter the building.

Is your temperature 100 degrees Fahrenheit or greater today? *

Yes - You cannot enter the building.

In the last 10 days, have you tested positive for COVID-19 or are you still waiting for the test result? *

Yes - You cannot enter the building.

Have you had contact with anyone confirmed or suspected of having COVID-19 in the past 10 days? *

Yes - You cannot enter the building, unless you are fully vaccinated.

Acceptance *
Visitor Attestation

I confirm that I am not showing symptoms and have replied NO to all questions above.

I confirm that I am showing COVID symptoms, OR have replied YES to one or more questions above.

Your Name

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