Covid-19 Student Health Questionnaire
For your dancer's safety and the safety of all staff and students, before you arrive at the studio each day for any in-person classes, this form must be completed.  

This form is required to be completed prior to entering  the building. If any answers are found to be inaccurate this will be grounds for immediate dismissal from the program.

Note:  Students may be subjected to temperature checks.

Reminder:
Everyone must wear a mask in order to enter the building and at all times while in the building.

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Email *
Student Name *
Parent/Guardian Name *
Cell Phone *
Have you started exhibiting any of the following COVID-19 symptoms in the last 10 days? 
 A fever (temp over 100.4 F or 38 C) without having taken any fever-reducing medications? *
Required
Loss of smell or taste? *
Required
Coughing? *
Required
Muscle aches? *
Required
Sore throat? *
Required
Congestion or runny noise? *
Required
Shortness of breath? *
Required
Chills? *
Required
Headache? *
Required
Have you experienced any new gastrointestinal symptoms such as nausea, vomiting, diarrhea, or loss of appetite in the last few days? If so do not enter the building and  email ipbacademy1@gmail.com for further consultation. *
Required
Have you, or anyone you have been in close contact with, been diagnosed with COVID-19 or placed in quarantine for possible exposure to COVID-19 within the last two weeks? If so do not enter the building and  email ipbacademy1@gmail.com for further consultation. *
Required
Have you been asked to self-isolate or quarantine by a medical professional or local public health official in the last two weeks? If so do not enter the building and  email ipbacademy1@gmail.com for further consultation. *
Required
If you have travelled outside the state of California, or by plane, train, ship or bus anywhere further than 50 miles from your home, the following quarantine protocols are in place: Vaccinated students (2 weeks past your second dose) – no quarantine necessary Non-vaccinated students – 7 days with no symptoms, If so do not enter the building and  email ipbacademy1@gmail.com for further consultation. *
Required
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