Emerge Dance Academy's COVID-19 Mandatory Before Class Checklist
Student Name *
Today's Date *
MM
/
DD
/
YYYY
Does the student named above have any of the following symptoms: *
Yes
No
Fever (Higher than 38.0 C)
Cough
Shortness of Breath / Difficulty Breathing
Sore Throat
Runny Nose
Has the student named above or anyone in their household travelled outside of Canada in the last 14 days? *
Has the student named above or anyone in their household been in contact with anyone being investigated OR with a confirmed case of COVID-19 in the last 14 days? *
Is the student named above currently being tested for a possible case of COVID-19? *
Has the student named above tested positive for COVID-19 within in the last 14 days? *
COVID-19 Release - I understand and agree that even with social distancing and sanitization protocols, there is a possibility of contracting COVID-19 (coronavirus disease) while attending Emerge Dance Academy. I voluntarily agree, therefore, to assume all risks and responsibility of contracting COVID-19 which me or my child may contract during any of Emerge Dance Academy Inc classes, rehearsals, performances, or activities. I also exempt and release, Emerge Dance Academy Inc and its owners, employees, assistants, volunteers, guest artists, and/or students from any and all liability claims, demands, or causes of action whatsoever from any damage, loss, injury, or death to me, my children, or property which may arise out of or in connection with COVID-19. I agree and give full consent to active symptom screenings for my child which may include a temperature check. I understand and agree that I will not send my child to Emerge Dance Academy Inc if they are sick even if symptoms resemble a mild cold. Symptoms to look for include fever, cough, shortness of breath, sore throat, runny nose, nasal congestion, headache, and a general feeling of being unwell. I understand and have made my child aware that they are to inform an Emerge Dance Academy Inc staff member immediately should any of the above-mentioned symptoms develop while at Emerge Dance Academy Inc. Should this occur I understand my child will be isolated until they are picked up by a parent or guardian. I understand it is my responsibility to ensure my child is picked up immediately when notified. I understand and agree that CMOH Order 05-2020 legally obligates individuals who have a fever, cough, shortness of breath, sore throat, runny nose (that is not related to a pre-existing illness or health condition) to be in isolation for 10 days from the start of symptoms or until symptoms resolve, whichever takes longer. I have alerted Emerge Dance Academy Inc of any and all medical conditions and allergies of my child. I understand it is especially important to alert Emerge Dance Academy Inc of any health conditions my child has which may causes similar symptoms of COVID-19. These health conditions and symptoms include but are not limited to a cough and/or shortness of breath due to asthma or exercise induced asthma, and/or a sore throat, runny nose and/or nasal congestion due to severe seasonal allergies. If I am signing this waiver for my child or children, I certify that I am the parent or legal guardian and have the right to waive these rights. *
Required
Guardian Name *
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