Studio 5.6.7.8 COVID Screening Form 2021-2022
At Studio 5.6.7.8 Inc, our top priority is the health and safety of our dancers!  

Please fill out this form for your child on the day of their class prior to arriving at the studio.  The screening form must be completed everyday that your child attends class at the studio.   If you are showing any symptoms, or answer yes to any Y/N questions, please stay home and follow public health isolation guidelines.

Last updated: March 21st, 2022
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Name of dancer
Date of Class:
MM
/
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/
YYYY
Are you experiencing any of the following symptoms?   Choose any that are new, worsening, and not related to other known causes or conditions you already have.
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
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In the last 5 days, have you shown symptoms associated with COVID-19 or tested positive for COVID-19 (rapid test or PCR test)? *
In the last 5 days, has someone you live with shown symptoms associated with COVID-19 or tested positive for COVID-19? *
In the last 14 days, have you travelled outside of Canada? *
If yes, please be sure to follow current federal requirements for travel.  https://travel.gc.ca/travel-covid/travel-restrictions/exemptions
If you or someone in your household has COVID-19 symptoms, click the link below to view the Brant County Health Unit flowchart for next steps...
https://www.bchu.org/ServicesWeProvide/InfectiousDiseases/PublishingImages/Pages/Information-for-Positive-or-High-Risk-Cases/Ministry%20Document%20-%20Symptoms%20%28March%209%2c%202022%29.pdf
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