Ballet Chicago Health Screener
Please answer the following questions yourself, or on behalf of your Ballet Chicago student if the child is under 18 years of age, no later than 90-minutes prior to your/your child’s arrival at Ballet Chicago each day that you/your child is scheduled to attend in-person classes.  

If you answer YES to any of the health screening questions, you/your child must stay home.  If you answer YES to any of the health screening questions, please complete the health survey and then go to https://www.dph.illinois.gov/covid19 or https://cookcountypublichealth.org/communicable-diseases/covid-19/ or https://www.chicago.gov/city/en/sites/covid-19/home.html websites for additional guidance.

Failure to comply with submitting the daily health screening will result in you forfeiting your/your child’s in-person class for the day of noncompliance.

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Email *
Student, Staff, or Guest Name *
Student Level *
Today's Date *
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Have you been fully vaccinated? *
Has the student/staff/guest been diagnosed with COVID-19 within the past 14 days? *
Is the student/staff/guest under evaluation for COVID-19 (for example, waiting for the results of a test to confirm infection)? *
Has the student/staff/guest experienced any new or unexpected symptoms consistent with COVID-19 including any chills, cough, shortness of breath or difficulty breathing, fever, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea within the last 72 hours? *
Has the student/staff/guest experienced a fever above 100.4 F within the last 72 hours? *
Within the past 14 days, are you aware of the student/staff/guest or anyone in your household having been in close contact with a lab-confirmed or suspected COVID-19 case patient or someone with clinically-compatible symptoms of COVID-19? *“Close Contact” is defined by the CDC as someone who was within 6 feet of an infected person for at least 15 minutes starting from 2 days before illness onset (or, for asymptomatic clients, 2 days prior to positive specimen collection) until the time the patient is isolated. The CDC says that close contact can occur when: (1) You provided care at home to someone who is sick with COVID-19 (2) You had direct physical contact with the person (hugged or kissed them) (3) You shared eating or drinking utensils (4) They sneezed, coughed, or somehow got respiratory droplets on you* *
Do you wear a mask when in public? *
Do you declare that the information stated above is true and correct? *
Parent/Guardian/Staff Name *
Parent/Guardian/Staff Phone Number *
Name of Adult available for pick up during today’s class time *
Phone Number of Adult available for pick up during today’s class time *
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