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The Dance Element - Covid-19 Screening
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* Indicates required question
Email
*
Your email
Dancer's Name
*
Your answer
Date of Dance Class
*
MM
/
DD
/
YYYY
Parent/Guardian's Name
*
Your answer
Phone number
*
Your answer
Are you or your dancer currently experiencing any of the following symptoms?
*
Fever and/or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher?
Cough or barking cough (croup) (Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions they already have))
Shortness of breath (Not related to other known causes or conditions - ex. asthma)
Decrease or loss of taste or smell (Not related to seasonal allergies, neurological disorders, or other known causes or conditions they already have)
Nausea, vomiting and/or diarrhea (Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions they already have)
None of the above
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