Ferocity Dance Company Student / Visitor Health Screening Questionnaire
In order to prevent the spread of the coronavirus and reduce the potential risk of COVID-19 exposure to our dancers, we are asking everyone to complete and submit this questionnaire prior to entering the studio. This must be filled out every time you will be entering our office or studio to participate in an activity or meeting of any sort - do NOT fill this out earlier than the day you're coming to our studio. Please do not enter the studio until your responses have been reviewed and your entry has been approved. Please note that as is stated on our website, dishonesty in this questionnaire will result in a permanent ban from the studio.
Email address *
Today's Date *
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Full Name: *
Date of Birth *
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Contact Phone Number *
In the past 48 hours have you had any of the following? *
Required
Are you ill, or caring for someone who is ill? *
Did you celebrate Thanksgiving with people that do not live with you and you have not been quarantining with? For the purposes of this questionnaire celebrate means shared a meal with, and spent extended periods of time together indoors / outdoors. *
Have you been at a social gathering with more than 10 people within the last two weeks? *
Have you smoked hookah in a social setting within the last two weeks? *
Have you been to a social dancing event (private or public) within the last two weeks? *
Have you been in close contact with anyone who has exhibited any symptoms within the last two weeks? *
Have you been in contact with anyone who has tested positive for COVID-19 within the last two weeks? *
Have you been tested for COVID-19 and are waiting to receive test results? *
In the past 14 days, have you traveled outside of the state of VA? *
In the past 14 days, have you been on a commercial flight? *
In the past 14 days, have you traveled outside of the United States? *
Do you hereby certify that the responses provided above are true and accurate to the best of your knowledge? *
A copy of your responses will be emailed to the address you provided.
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