Pupils Self-Declaration for Return to School.

Covid 19 Questionnaire/Self-Declaration- Pupils

In the interests of the health and safety of the entire community of WPJS, you are required to complete the following questionnaire/declaration on behalf of your child. Thank you for your co-operation.
1. Does your child, or anyone in your household, have any of the following typical COVID-19 symptoms: persistent cough, fever, high temperature, sore throat, breathlessness or flu like symptoms now or in the past 14 days?
2. Has your child been in close contact with anyone with confirmed or suspected COVID-19 in the last 14 days?
3. Does your child live in the same household with anyone who has symptoms of COVID-19 and/or who has been in self-isolation in the last 14 days?
4. Has anyone in your household been advised by the HSE that they are a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days?
5. Has your child, or anyone in your household, returned to the island of Ireland from another country within the last 14 days?
If YES to question 5, from where?
If YES to Question 5, what was the date of return to Ireland
6. Have you been advised that your child is in a very high risk group? And/or has your child been recommended to self-isolate/cocoon due to an underlying medical condition?
If you have answered “Yes” to any of the above questions, please contact the Principal directly

Please fill in your name below to indicate you agree to the following statements. This will stand in place of your signature.

I confirm that I have responded to the above questions truthfully based on my child’s current condition.I understand that if I have answered “Yes” to any of the above questions, my child cannot return to school in Willow Park JS until so agreed with the Principal James Docherty
Parent full name
Sons Full Name
You must fill out a separate form for each child in the school
Sons Form and class e.g 5th Form St John's
04 2021
End of Term 3
Willow Park Junior school,
Co. Dublin,

01 288 1651

School Account
Extra Account
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