Lesson Check-In Questionnaire

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Please complete this questionnaire each week before you arrive for your lesson. You may also check-in at the front desk when you arrive. Thank you!

Email *

Name and Today's Date *

For Youth: What is the best phone number to call or text should there be any issues during your lesson today? Please include name of person.

Are you currently experiencing any symptoms of illness (including but not limited to: runny nose, nasal congestion, cough, headache, nausea, vomiting, fever, diarrhea, chills, shortness of breath, loss of taste or smell, fatigue, sore throat, muscle/body aches) (not associated with any chronic issues/illnesses)? *

Yes

Required

If Yes, please list all symptoms you are currently experiencing.

Have you experienced any symptoms of illness in the past week? *

Yes

If yes, have you been symptom free (without medication) for at least 72 hours?

Yes

Clear selection

Are any family members currently experiencing any symptoms of illness? *

Yes

Have any family members experienced any symptoms of illness in the last week? *

Yes

If yes, have they been symptom free (without medication) for at least 72 hours?

Yes

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Have you or a family member tested positive for COVID in the last 10 days? *

Yes

Have you or a family member been exposed to anyone who has tested positive for COVID in the last 10 days? *

Yes

Have you or a family member travelled anywhere with high COVID cases in the last 2 weeks? *

Yes

Due to the nature of COVID, there is always the risk of exposure (even with strict protocols in place) when studying music in-person. Do you acknowledge and accept the risk of taking in-person lessons? If no, we will move your lessons online. *

Yes

FOR ADMIN: Record Temperature

FOR ADMIN: Health Check-In Passed?

Yes

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