Covid-19 Dancer Wellness Screening
The safety of our dancers and employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure, we are asking everyone to complete and submit this questionnaire prior to entering the studio.

Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and other dancers and staff.
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Dancer Name *
Class/Classes attending *
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Cough, Shortness of breath or difficulty breathing, Sore throat, New loss of taste or smell Chills, Head or muscle aches, Nausea, diarrhea, vomiting. *
Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)​ ​Please take your temperature before you answer this question. *
In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *
In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *
Have you been tested for COVID-19 and are waiting to receive test results? *
Have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms? *
I hereby certify that the responses provided above are true and accurate to the best of my knowledge. *
Parent/Guardian Name *
Parent/Guardian Signature (please sign with /s/ and your name) *
Date signed *
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