Dance Evolution COVID-19 Questionnaire
This is questionnaire is to be filled out EACH visit BEFORE you or your child comes to class. It is mandatory to enter the studio.

If you answer 'Yes' to any of the following questions, you are not permitted to enter the studio.
If you answer 'No' to any of the following questions, we look forward to seeing you.

*Please note* if you show any symptoms, you must not return to the studio until you are 48 HOURS symptom free.
Email Address *
Today's Date? *
MM
/
DD
/
YYYY
Dancer's First and Last Name *
Parent's Name *
Are you sick with a cold/flu or are you displaying any signs of COVID-19 and/or flu-like symptoms?
Clear selection
Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?
Clear selection
Have you returned from outside the country (including Canada / USA) in the past 14 days?
Clear selection
In the past 14 days, at work or elsewhere, did you have close contact with someone who has a probable or confirmed case of COVID19?
Clear selection
In the past 14 days, at work or elsewhere, did you have close contact with a person who had acute respiratory illness that started within 14 days of their close contact to someone with a probable or confirmed case of COVID-19?
Clear selection
In the past 14 days, at work or elsewhere, did you have close contact with a person who had acute respiratory illness who returned from travel outside of the country in the 14 days before they became sick?
Clear selection
In the past 14 days have you been directed by Public Health to self-isolate?
Clear selection
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy