Mudra Dance Studio Wellness Form
This form must be completed the 24 hours prior to attending any in person classes. If you answer yes to any of the symptom/travel questions, you will not be permitted in the dance studio for 14 days (2 classes).
Please answer the below questions as though "you" is the student attending.

Covid rules are as follows:
~8-12 ft distanced, staggered dancers/drummers (refer to the image)
~temperature checks at the door
~form completion 24 hours before class
~closure of dressing room & communal water fountain
~1 bag per person required, which should fit all belongings in it
~students may bring their water bottle into the studio room and keep it within their designated area
~direct route from door to studio, without crossover
~sanitizing station at entrance to lobby and to each dance studio
~stagnant choreography (no travel or contact)
~sanitization of barres, floors, and frequently touched surfaces between every class
~no changing of dance studios during class, each class stays in their studio the entire class time
~drop-off only for all students
~staggered class times (by last names) to reduce lobby gathering
~parents will have a sign with their kid's name in the dash board during pick-up
Email *
First Name (of student) *
Last Name (of student) *
Phone Number *
Class *
Do you (the student) have a cough? *
Do you have a fever now or have you in the past 14-21 days? *
Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days, without the proper PPE? *
Are you experiencing shortness of breath or difficulty breathing? *
Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue? *
Have you experienced recent loss of taste or smell? *
Are you (the student) over the age of 60 *
Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders? *
Have you traveled in the past 14 days to any regions affected by COVID-19? *
Never submit passwords through Google Forms.
This form was created inside of Mudra Dance Studio. Report Abuse