COVID-19 Health Check
Artistry in Motion Performing Arts Center
* Required
First Name
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Your answer
Last Name
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Your answer
Date of Birth
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Has anyone in your household traveled outside of the United States of America in the last 14 days? (Answering YES may prompt us to ask you more questions to determine if you are eligible to enter our facility
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Yes
No
Has anyone in your household had contact with anyone with suspected or confirmed COVID-19 in the last 14 days? (Answering YES may prompt us to ask you more questions to determine if you are eligible to enter our facility.)
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Yes
No
Has anyone in your household had any of these symptoms in the last 14 days: fever, chills, difficulty breathing or shortness of breath, dry cough? (Answering YES may prompt us to ask you more questions to determine if you are eligible to enter our facility.)
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Yes
No
Is anyone in your household currently experiencing fever, difficulty breathing or cough? (Answering YES may prompt us to ask you more questions to determine if you are eligible to enter our facility.)
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Yes
No
I understand by filling out this form, AIMPAC, it's staff, and instructors will be this released of all liabilities as they will undergo the same protocol as our families, whether a COVID-19 infection occurs before, during, or after participation in any program. I understand that answering "no" could result in AIMPAC denying myself and my family from entering Artistry in Motion's facility. Do you agree that you have read and accept the Virus Acknowledgement?
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Yes
No
I am filling out this form on behalf of:
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Myself
A minor
Please confirm your answers by selecting below:
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I certify that the information I have provided is accurate and complete.
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Signature
Your answer
Today's date
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