DDA Dance Academy- Daily COVID-19 Screening Questionnaire for In-Person Classes
THESE QUESTIONS MUST BE ANSWERED BEFORE EACH DAY ATTENDING DDA AT LEAST 1HR PRIOR TO IN-PERSON CLASSES (40 Eisenhower Drive Ste.102 Paramus, NJ 07444)
First and Last Name of Participant
Date of Attendance/Class/DDA event
Have you or anyone in your home had contact within the last fourteen days with any person under screening/testing for COVID-19, or with anyone with known or suspected COVID-19?
Do you currently have any of the following symptoms? *Fever (100.4°F or higher), or a sense of having a fever (chills/body aches). *Fatigue *New cough that you cannot attribute to another health condition. *New shortness of breath that you cannot attribute to another health condition. *New sore throat that you cannot attribute to another health condition. *New muscle aches that you cannot attribute to another health condition or that may have been caused by a specific activity (such as physical exercise).
Yes - If you answer YES to any of these screening questions, please stay at home until advised otherwise by your doctor. If you'd like to take the class virtually contact us at 201-819-7989 or
* I understand the above symptoms and affirm that I, as well all household members, do not currently have, nor experienced the symptoms above within the last 14 days. *I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days. * I affirm that I, a well as all household members, have not travelled outside of the US, or to any city of our own that is or has been considered a "hot spot" for COVID-19 infections within the last 30 DAYS *I understand that DDA Dance Academy LLC cannot be held liable for any exposure to the COVID-19 virus or any other contagion caused by misinformation on this form or the health history provided by each client. *I understand that if any of the above has changed I must inform DDA Dance Academy immediately
I AGREE TO EACH STATEMENT ABOVE and release DDA Dance Academy LLC from any and all liability for the unintentional exposure or harm due to COVID-19.
I DO NOT AGREE TO EACH STATEMENT AND WILL NOT ATTEND CLASS at this time until cleared to do so- CONTACT
to see if their is a virtual class option
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