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    Print the "Travel Survey for Orange County Students and Staff"

    Travel Survey for Orange County Students and Staff 

    School Information
    (To be completed by school personnel) 

    School Name: _____________________________________________

    School Address:
    _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    School Contact Name: ____________________________________

      Telephone Number: _______________________________



    Personal  Information (To be completed by student and/or school personnel) 

    Student or Staff Name:  ___________________________________                                                  Date of Birth: _____________

    Address____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

     

    Grade: __________________

    (Student Only) Parent/Legal Guardian Name: _______________________________

    Telephone Number: __________________________

    Trip Information 

    Travel Destination: ______________________________

    Departure Date: ____________________________________

    Return Date: _______________________________________

    Transportation (if known): Select all that apply 

    Airplane              Bus         Private Car                Ship/Cruise    Taxi

    To Be Completed by Health Care Worker Only: 

    Travel to designated geographic area of interest Yes or No 

    If yes, country name: 

    Letter of Clearance 

    Issue date: 

    Issued by:

    Created 03/03/2020 

Last Modified on March 12, 2020