DDA Dance Academy- Daily COVID-19 Screening Questionnaire for In-Person Classes

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THESE QUESTIONS MUST BE ANSWERED BEFORE EACH DAY ATTENDING DDA BY THE PARENT OR GUARDIAN, AT LEAST 1HR PRIOR TO IN-PERSON CLASSES (40 Eisenhower Drive Ste.102 Paramus, NJ 07444)

First and Last Name of Parent/Guardian *

First and Last name of Participant (s) *

Date of Attendance/Class/DDA event *

YYYY

Has your child or has anyone in your home had contact within the last fourteen days with any person under screening/testing for COVID-19, or with anyone with known or suspected COVID-19? *

Yes

Does your child currently have any of the following symptoms? *Fever (100.4°F or higher), or a sense of having a fever (chills/body aches). *New cough that you cannot attribute to another health condition. *New shortness of breath that you cannot attribute to another health condition. *New sore throat that you cannot attribute to another health condition. *New muscle aches that you cannot attribute to another health condition or that may have been caused by a specific activity (such as physical exercise). *

Yes - If you answer YES to any of these screening questions, please have your child stay at home until advised otherwise by your doctor.

Required

I understand the above symptoms and affirm that I, as well all household members, do not currently have, nor experienced the symptoms above within the last 14 days. *I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days. * I affirm that I, a well as all household members, have not travelled outside of the US, or to any city of our own that is or has been considered a "hot spot" for COVID-19 infections within the last 30 DAYS *I understand that DDA Dance Academy LLC cannot be held liable for any exposure to the COVID-19 virus or any other contagion caused by misinformation on this form or the health history provided by each client. *I understand that if any of the above has changed I must inform DDA Dance Academy immediately *

I AGREE TO EACH STATEMENT ABOVE and release DDA Dance Academy LLC from any and all liability for the unintentional exposure of harm due to COVID-19.

I DO NOT AGREE TO EACH STATEMENT AND WILL NOT ATTEND CLASS at this time until cleared to do so- CONTACT info@ddadance.com to see if their is a virtual class option

Required

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