Spreading the Music Corona Virus Screening Questionnaire
This form is to provide additional safety information and contact tracing during the COVID-19 Pandemic. Please note, it is required to wear a face-mask upon entering Spreading the Music, wash your hands immediately after entering the building, no excessive touching and practice good hygiene. We will not, in any circumstances, share your personal information with other individuals or organizations without your permission, including public organizations, corporations or individuals, except when applicable by law.
* Required
Parent First, Last Name
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Your answer
Student First, Last Name (Having the Lesson)
*
Your answer
Best Contact Phone Number
*
Your answer
Students Date of Birth
*
MM
/
DD
/
YYYY
Home Address (Not Required)
Your answer
Are you or the student having shortness of breathing other difficulties breathing?
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Yes
No
Do you or the student have a cough?
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Yes
No
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
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Yes
No
Have you or the student experienced recent loss of taste or smell?
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Yes
No
Are you or the student in contact with any confirmed COVID-19 positive patients?
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Yes
No
Is your or the students age over 60?
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Yes
No
Do you are the student have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
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Yes
No
Have you or the student traveled in the past 14 days to any regions affected by COVID-19? (as relative to your location)
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Yes
No
Have you tested positive to COVID-19?
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Yes
No
Date of Lesson
MM
/
DD
/
YYYY
Time of Lesson
Time
:
AM
PM
Signature of Parent or Student
Students who are well but who have a sick family member at home with COVID-19 should consider postponing your lesson. Positive responses to any of these would likely indicate a deeper discussion with your teacher before deciding to proceed. By having this lesson I understand there is a heightened risk of contracting or transmitting the Corona Virus and can opt for online lesson at anytime. By signing this form, I have taken the required safety precautions before entering Spreading the Music, I feel safe and am ready to have music lessons in person.
Signature
*
Your answer
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