COVID - 19 Screening Form
Version 2 - Sunday November 22
Dancer Name *
Email Address *
Phone Number
Do you (or the person you are filling this form out for) have any of the following new or worsening symptoms or signs? *
Please check all that apply
Yes
No
New or worsening cough
Shortness of breath
Sore throat
Runny nose, sneezing or nasal congestion (in absence of underlying reasons of symptoms such as allergies, and post-nasal drip)
Hoarse voice
Difficulty swollowing
New smell or taste disorder(s)
Nausea/vomiting, diarrhea, abdominal pain
Unexplained fatigue/malaise
Chills
Headache
Travelling *
Yes
No
Have you travelled outside of Canada or had close contact with anyone who has travelled outside of Canada in the past 14 days?
Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19
Fever (please take temperature daily) *
Please take temperature and record below. If your temperature is 37.8' or higher, you are not permitted to come into camp or class as that is considered a fever temperature.
Yes
No
Do you have a fever?
IMPORTANT
If your dancer has any of the above symptoms or has come in contact with someone who has, or potentially has COVID, please DO NOT have your dancer attend class. Please contact the health department immediately and send us an email at office@take5dance.com.
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