COVID-19 Pre-Screening Form
This form must be filled out the same day you come to class. If you come to class multiple days a week, this form must be filled out on EACH DAY that you come to the studio.

**Dancers who have not filled out this form will be denied entry into the studio, and will not be allowed in until the form is filled out.

Please answer the following questions with "Yes" or "No":

1. Have you been experiencing ANY of the following symptoms? Please DO NOT include symptoms that are chronic, or related to pre-existing conditions.

Shortness of breath
Sore throat
Chest pain
Decrease or loss of sense of taste and/or smell
Headaches (that is new or persistent, unusual, unexplained, or long-lasting)
Fatigue/muscle aches
Nausea, vomiting, diarrhea, abdominal pain
Runny nose/Nasal congestion

2. Have you been identified as a close contact of someone who has tested positive for COVID-19, by your local public health unit (or another authority)?

3. Have you been directed by a health care provider, or another authority to self-isolate?

4. Have you traveled outside of Canada, or been in close contact with anyone who has traveled outside of Canada, in the last 14 days?

5. Do you have a confirmed case of COVID-19 or are you currently awaiting test results?

If you have answered "Yes" to any of these questions, please call 905-553-7610 or email
Dancer Name *
Parent Name
Today's Date *
Have you answered yes to any of these questions? *
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