Crossings COVID Screening Questionnaire
Before attending class or entering the studio, we kindly ask that you complete the following health & safety questionnaire...
* Required
Email address
*
Your email
Please check the box if you have any of the following symptoms:
*
Fever (greater than 38.0C)
Cough
Shortness of breath/Difficulty breathing
Sore throat
Runny nose
Or ... I feel FIT TO DANCE!
Required
Have, you or anyone in your household travelled outside of Canada in the last 14 days?
*
Yes
No
Have you, or anyone in your household been in contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?
*
Yes
No
Are you currently being investigated as a suspected case of COVID-19?
*
Yes
No
Have you tested positive for COVID-19 within the last 10 days?
*
Yes
No
Date completed
*
MM
/
DD
/
YYYY
Signature (First & Last Name)
*
Your answer
Send me a copy of my responses.
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