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 at all times, wash your hands immediately upon 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.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Students Full Name (If applicable) *
Best Contact Phone Number *
Students Date of Birth *
MM
/
DD
/
YYYY
Do you or the student experience easy shortness of breath or other mild to severe difficulties breathing? *
Do you or the student have a cough? *
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *
Have you or the student experienced recent loss of taste or smell? *
Have you or the student been in contact with any confirmed COVID-19 positive patients in the past 7 days? *
Are you or the student over the age of 60? *
Do you are the student have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders? *
Have you or the student traveled out of the country or to a high-risk region in the past 14 days? (as relative to your location) *
Have you ever tested positive to COVID-19? *
Date of Lesson
MM
/
DD
/
YYYY
Time of Lesson
Time
:
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 or variants 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, teach a lesson or comfortably use rehearsal space.
Signature *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy