The Dancing Elephant COVID-19 Survey
We care deeply about the health of our students, teachers, and community. As we re-open to small, in-person classes both indoors and outdoors, we ask every student to review our COVID-19 Health Protocols posted on our website and to answer the questions below before coming to class. If you answer "Yes" to any of the COVID-19 health questions or do not meet the State of Maine entry criteria, you unfortunately are not allowed to attend in-person classes at this time. You may join our online classes via Zoom. Visit for more information about all of our classes. Thank you!
Date *
Your Full Name *
Your Email Address *
The class or retreat you plan to attend: *
I have read and understand the COVID-19 Health Protocols on The Dancing Elephant website ( *
COVID-19 Health Questions: Do you currently have – or have you had in the last 14 days – any of the following symptoms: fever, chills, sore throat or cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, new loss of taste or smell, or nausea, vomiting or diarrhea? *
Have you come in contact with any known or suspected COVID-19 cases in the last 14 days? *
Have you had close, sustained contact with large groups of people in the past 14 days? *
Have you traveled to any COVID-19 hot spots (e.g. Boston or New York) in the past 14 days? *
Please check the box that best describes how you comply (or not) with the State of Maine COVID-19 entry criteria: *
AGREEMENT OF RELEASE AND WAIVER OF LIABILITY: I agree that my current health and physical condition support my participation in programs at The Dancing Elephant. I agree that I am ultimately responsible for my own safety and for participating as I am able. I acknowledge that I am participating at my own risk. If I have questions about my health, I will consult with my physician and seek his/her approval for participation if necessary. I release and waive any liability or claim I may have resulting from participation in classes at The Dancing Elephant. I have read this Agreement of Release and Waiver of Liability, and I fully understand its contents. I voluntarily agree to the terms and conditions stated above.
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If you have any other information to share with us, please respond here. Thank you!
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