COVID-19 Weekly Screening Questionnaire
For the health and safety of you, our dancers, teachers, and others, Parents/guardians are REQUIRED to fill out this form EVERY WEEK on behalf of your dancer, on the day of class by 3:00pm, so that your dancer may attend. Thank you for your understanding and cooperation! (You will receive a copy of your responses via email as a confirmation of the form being submitted)
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Email *
Student Information:
Student Name *
Students' Class *
Required
COVID-19 Questions:
Have you (or anyone entering with you) experienced any of the following symptoms in the past 48 hours:  • fever of 100 or higher  • chills  • cough  • shortness of breath or difficulty breathing  • new loss of taste or smell  • fatigue  • nausea or vomiting  • diarrhea  • muscle or body aches  • headache  • congestion or runny nose (not already attributed to another cause) *
Are you (or anyone entering with you) currently waiting on the results of a COVID-19 test, had a positive test within the past 10 days, or are worried about being sick with COVID-19? *
Within the past 14 days, have you (or anyone entering with you) been in close physical contact (6 ft or closer for at least 15 minutes) to a person with COVID-19 (laboratory-confirmed and/or with consistent symptoms)? *
Did you answer NO to ALL QUESTIONS?
Your dancer's class attendance for today has been APPROVED. We look forward to seeing you all! Thank you for helping us protect you and others at this time.
Did you answer YES to ANY QUESTION?
Please keep your dancer at home at this time. [Students must be “fever-free”, for 72 hours before returning to dance classes. Students who test positive for COVID-19 will be required to quarantine for 14 days. If they choose to have a follow up test and it comes back negative, they may return to dance class with a doctor’s note.] If you are interested in attending this week's class virtually via ZOOM instead, please complete the following question so we may set that up for you! Thank you!
Virtual Class Request (for those who answered YES to any screening question)
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Parent/Guardian Name (if under 18) *
A copy of your responses will be emailed to the address you provided.
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