SBDA Health Screening Form & Protocol Agreement/Waiver

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Email *

Dancer Name *

Guardian name (who is filling out this form) *

Guardian relationship to dancer: *

Guardian phone number (to call/text if needed) *

Emergency contact if guardian is unreachable (name & phone number) *

Class(es) attending/enrolled in (include style, level, and section) *

Please answer the following questions, as they apply to your dancer today (if responses to any of these questions change in the future, please make sure to re-enter this form via the unique link emailed to you, to edit your responses and resubmit). *

The dancer has run a fever in the last 48 hours

The dancer has exhibited COVID-19 symptoms in the last 10 days

The dancer has a cough or breathing concerns

The dancer has traveled in the last 10 days

The dancer has had a positive COVID-19 test

The dancer has had contact or exposure to COVID-19

The dancer has other medical concerns (detailed/noted in his/her profile in the SBDA Jackrabbit portal/database)

None of the above

Other:

Required

(Please explain if any of the above boxes were checked) *

In the event that my dancer needs to use the bathroom facilities: (check any that apply) Note: Helpers and SBDA staff members will not be aiding in toileting. Please make sure dancers who are unable to toilet themselves have a guardian on the premises at all times. *

I will be on site within SBDA premises, in one of the designated waiting areas.

Please call me in from my vehicle to assist my dancer, using my phone number indicated above

My dancer is capable of self-toileting and will wash hands thoroughly for the CDC-recommended allotted time

Required

Check one of the following to indicate your availability while your dancer is in class: (Note: In the event that the dancer has multiple classes on the same day/back to back, it is advised that individuals not wait in common areas including the lobby, break room, or playroom. Dancers with breaks in between classes must maintain physical distance, not share food/drink, and in the event that time between classes is more than 60 minutes, a guardian must pick up to vacate SBDA premises during the interim, returning in time to check in for next class.) *

I will be on site within SBDA premises, in one of the designated waiting areas.

I will wait in the parking lot at SBDA while my dancer is in class

My dancer has back-to-back classes and this form serves to check him/her in for the duration.

I will return to check out and pick up my dancer (curbside) exactly when the class finishes, which is at the time designated below (write in "other" field below)

Other:

Required

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