IMPORTANT NOTE: Individuals with a temperature over 100° or answer of “YES” to any symptoms from screening questions will not be permitted in a dance studio.

Name *

First Name

Last Name

Email *

1. Fever-free and symptom-free individuals will be provided and required to: *

- Wear a face mask at all times - Practice hand hygiene upon arrival to the facility - Maintain 6 feet distance from all others

2. Temperature Screening *

All individuals will be screened for fever.

3. Symptom Screening

In the last 2 weeks, have you had any of the following symptoms?

- Fever (Had a Fever or Felt Feverish) *

YES

- Shortness of breath *

YES

- Cough *

YES

- Chills *

YES

- Repeated shaking with chills *

YES

- Sore throat *

YES

- Muscle / body aches *

YES

- Headache *

YES

- Nausea, vomiting or diarrhea *

YES

- New loss of sense of taste or smell *

YES

Electronic Signature *

The electronic signature below, and all of its related fields, replaces a handwritten signature on paper and is legally binding. I affirm that the information provided is true, correct and complete, to the best of my knowledge and belief. This electronic signature below and its related fields are treated by the district like a handwritten signature on a paper form.

Date *

YYYY

Thank you!