Weekly Return to Dance Questionnaire
This form is due bi-weekly for any dancer wishing to enter the studio for classes, private lessons, or any other reason. Dancers will not be permitted if this form is not submitted by a parent or guardian bi-weekly. Please use honesty and common sense. Please contact the studio if you have any questions before submitting. You are required to contact the studio immediately if the answers to this questionnaire become false before your next weekly submission is due.
Dancer's First and Last Name *
Today's Date *
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*Has your dancer or anyone in your household attended an event or setting, school, or other activity in the past 14 days with a crowd of more than 10 people who did not social distance and/or wear a mask? *
Have you/your dancer or anyone in your household recently traveled to an area that has been designated by the CDC as a Level 3 travel warning due to known local spread of COVID-19? Yes or No *
During the past 14 days, have you/your dancer or anyone in your household come into close contact (within 6 feet) with someone who has either had a laboratory confirmed COVID-19 diagnosis or is under investigation for potential COVID-19 infections and/or is awaiting lab results? Yes or No *
Do you/your dancer or anyone in your household have a fever greater than 100.4 OR symptoms of lower respiratory illness such as cough, shortness of breath or difficulty breathing? Yes or No *
I understand that while dancing with Barbie Rhodes Dance Studio,LLC in class, rehearsal , or performance, my child(ren) may be at risk of physical illness or injury (minimal, serious, catastrophic and/or death), and I acknowledge that my child is assuming the risk of illness or injury by dancing with Barbie Rhodes Dance Studio, LLC. I am aware that this Medical Release/Waiver exempts the liability of Barbie Rhodes Dance Studio, LLC and acknowledges my voluntary and knowing assumption of the risk of injury or illness. I have signed this document voluntarily and of my own free will. I further state that I am at least eighteen (18) years of age, and am fully competent to sign this document. I agree that my electronic signature is the legally binding equivalent to my handwritten signature. *
Parent or Guardian's First and Last Name *
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