COVID-19 Weekly Screening Questionnaire

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(Updated for Spring 2022) We will not be emailing the COVID-19 Screening Questionnaire each week. Only if you are unable to attend class because of symptoms, testing, or quarantine, you may fill out this questionnaire to request for your teacher to set up a live Zoom link of class to participate virtually, and we will try our very best to accommodate this request. Requests must be made by 3:00pm the day of class so teachers have time to prepare. Thank you!

Student Information:

Student Name *

Student's Class *

Maumelle/NLR: 3-4 Years (Ballet/Tap/Creative Movement/Worship) 4:15-5:00pm

Maumelle/NLR: 5-7 Years (Ballet/Tap/Jazz/Worship) 5:00-6:00 pm

Maumelle/NLR: 8 Years & Up (Ballet/Jazz/Contemporary/Worship) 6:00-7:00pm

Little Rock: 3-4 Years (Ballet/Tap/Creative Movement/Worship) 4:00-4:45pm

Little Rock: 5-7 Years (Ballet/Tap/Jazz/Worship) 4:45-5:45pm

Little Rock: 8 Years & Up (Hip Hop) 4:15-5:00pm

Little Rock: 8-10 (Ballet/Jazz/Contemporary/Worship) 5:00-6:00pm

Little Rock: 11 Years & Up (Ballet/Jazz/Contemporary/Worship) 6:00-7:00pm

Little Rock 14 Years & Up (Ballet/Jazz/Contemporary/Worship) 5:45-7:00pm

Required

COVID-19 Questions:

Have you (or anyone entering with you) experienced any of the following symptoms in the past 24 hours: • Fever (temperature 100.4 ºF or higher) • Sore throat • New cough that causes difficulty breathing • Recent loss of taste or smell • Diarrhea, vomiting, or stomachache • New onset of severe headache *

Yes

Are you (or anyone entering with you) currently waiting on the results of a COVID-19 test, had a positive test within the past 10 days, or are worried about being sick with COVID-19? *

Yes

Within the past 14 days, have you (or anyone entering with you) been in close physical contact (6 ft or closer for at least 15 minutes) to a person with COVID-19 (laboratory-confirmed and/or with consistent symptoms)? [EXCEPTIONS: You are fully vaccinated, have had COVID-19 within the past 3 months, and/or both parties in close contact were properly wearing masks] *

Yes

Yes, but Exception

Did you answer NO (or Exception) to ALL QUESTIONS?

Your dancer's class attendance for today has been APPROVED. We look forward to seeing you all! Thank you for helping us protect you and others at this time.

Did you answer YES to ANY QUESTION?

Please keep your dancer at home at this time. [Students must be “fever-free” without use of fever-reducing medications for 24 hours before returning to dance classes. Students who test positive for COVID-19 will be required to quarantine for 14 days. If they choose to have a follow up test and it comes back negative, they may return to dance class with a doctor’s note.] If you are interested in attending this week's class virtually via ZOOM instead, please complete the following question so we may set that up for you! Thank you!

Virtual Class Request (for those who answered YES to any screening question)

Yes, please send me a ZOOM link to the email address provided on this form.

Clear selection

Parent/Guardian Name (if under 18) *

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