COVID-19 Health Declaration Form2020-08-16T17:06:36-04:00

COVID-19 Pre-Screening Declaration

Participant Name:

Parent/Guardian Name (if participant is under 18):

Have you experienced a fever, or felt feverish within the last 14 days?
YesNo

Have you experienced a new cough in the last 14 days?
YesNo

Have you experienced shortness of breath in the last 14 days?
YesNo

Have you experienced any of the following flu-like symptoms in the last 14 days?
FatigueNauseaDiarrheaChills or Shaking with ChillsMuscle PainHeadacheSore ThroatLoss of taste or smellRashNone of the above

Have you or your family or close contacts travelled to the US or internationally in the past 14 days?
YesNo

Terms and Policies:
PLEASE NOTE: IF YOU HAVE ANY OF THE ABOVE SYMPTOMS… STAY HOME.

Masks must be worn in the common areas of the studio.

Temperature checks will be done upon entry for every person that enters the studio.

I understand all the potential risks related to COVID-19, and wish to proceed with my scheduled Dance Class(es).

I UNDERSTAND THIS EXPLANATION. MY QUESTIONS HAVE BEEN FULLY ANSWERED AND I WISH TO PROCEED WITH THE CLASS(ES) I AM REGISTERED FOR.