Primary COVID Health Screening

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

Are you taking a dance class with us in-person?

All registrants are required to fill out a health screening survey not more than 8-hours but no less than one-hour prior to arrival at DSBPA.

Certification of being COVID-19 symptom and exposure free.

Email *

Policy on Masks:

DSBPA requires all persons to wear masks while in the building regardless of vaccination status or living situation. Masks must be classified as either a N95 mask, K94, KN95 or a ASTM Level 3 hospital grade mask that is at least three-ply.

Most important is masks should multiple layered and fitted around the face and nose.

Student Name *

I am: *

Instructor/Administration

Student (over 5)

Student (under 5)

If eligible has your student been vaccinated? *

Not eligible

Yes- 1st dose

Yes- 1st & 2nd dose

Prefer not to say

Has student or anyone in household tested positive or been in close contact with someone who has received a positive COVID-19 test in the past 10 days or has had symptoms of COVID-19?* *

Yes *Do not attend in-person classes

Has student or anyone in household been advised to self-isolate from the health authority within 10 days as of today? * *

Yes *Do not attend in-person classes refer to COVID policy on website

Is student or anyone in household experiencing symptoms such as: chills, cough, shortness of breath, respiratory illness, sore throat, headache or new loss of taste/smell? *

None of above

Yes, experiencing symptoms *Do not attend in-person classes refer to COVID policy on website

Required

Has student or anyone in household been in contact with anyone who has been diagnosed or tested positive with COVID-19 in the past 10 days?* *

Yes *Do not attend in-person classes refer to COVID policy on website

I acknowledge; (1) I have completed the survey and my answers are accurate (2) I confirm student has NOT been exposed, tested positive, quarantined, or showing symptoms of COVID (3) I understand the contagious nature of COVID-19 and voluntarily assume the risk that we may be exposed to or infected by COVID-19 or variants of by attending DSBPA and that such exposure or infection may result in personal injury, illness, permanent disability, and death. *

As the responsible party, I acknowledge the above information.

Required

Name of person completing form *

Date *

YYYY

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