Dance Evolution: COVID-19 Student Screening
This form must be filled out truthfully and accurately PRIOR to coming to the studio for any dance classes each day. This helps us to keep track of who is present each day in case an outbreak were to occur.
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Today's Date *
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Dancer's Name (First & Last) *
Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has had symptoms of COVID-19? *
If the answer is YES, you must keep your dancer home for 14 days, or until your COVID test comes back negative.
Have you tested positive for COVID-19 in the past 14 days? *
If the answer is YES, you must follow the CDC and local health department's recommendations and quarantine until a negative test is indicated. You may NOT enter the studio until a negative test is confirmed.
Have you experienced any symptoms of COVID-19 in the past 14 days? (Fever over 100 degrees Fahrenheit, new or worsening cough, shortness of breath, body aches unrelated to physical activity, new loss of smell or taste, sore throat, nausea/vomiting, or diarrhea) *
If your dancer is experiencing ANY of the above symptoms, please keep your dancer home even if you think it may not be COVID related. Please note that muscle soreness and body aches may occur due to their dance training. However, body aches along with fever, chills, nausea, etc. would be an indicator to stay home.
In the last 14 days, have you traveled to another state or country for which New York State requires a mandated self-quarantine period? *
If the answer is YES then by NYS mandate you must quarantine for 14 days and are not permitted to enter the studio for the duration of your quarantine.
Do you understand that your dancers temperature will be taken upon arrival each day via a CDC approved infrared thermometer? *
Do you understand that if your dancers temperature registers at 100 degrees Fahrenheit or higher, they will be sent home for the day? *
Do you affirm that the responses on this form are accurate and truthful to the best of your knowledge?
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Parent Guardian Signature *
Please type your first and last name affirming your prior reseponse.
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