PITTSBURGH PERFORMANCE PROJECT '21-'22 Season COVID-19 Health Declaration

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

All Pittsburgh Performance Project staff and cast members are required to complete the below declaration 1 hour prior to all sanctioned events (e.g. rehearsal, performances, competitions) in order to participate in the 2021-2022 season. Those who do not submit this declaration will be turned away, and subject to removal from the program.

Your Full Name *

Today's Date - NOT YOUR BIRTHDAY *

YYYY

Your Email Address *

Your Cell Phone Number (XXX-XXX-XXXX) *

Have you been fully vaccinated for COVID-19? *

Yes

Have you been diagnosed with COVID-19 within the last 14 days? *

Yes

If you answered yes to the above, were you hospitalized? *

Yes

I was not diagnosed with COVID-19

Have you been in close contact with anyone exhibiting symptoms of COVID-19? *

Yes

Have you been asked to self-isolate or quarantine by a medical professional or public health official? *

Yes

Are you currently experiencing any of the following symptoms? *

Difficulty breathing/Shortness of breath

Severe chest pains

Dizzy

Loss of consciousness

Loss of smell

Loss of taste

Fever

Cough

Sweats

No, I am not experiencing any of these symptoms

Required

Have you traveled outside of the tri-state area (this includes international travel) within the last 14 days? *

Yes

COVID-19 LIABILITY WAIVER - Please read and acknowledge below:

Do you agree to the Liability Waiver presented above? *

Yes

Type your name below to confirm the information you have provided is truthful. *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms