VYbE Health Declaration Form

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Read carefully and checkmark all that apply. In order to access VYbE Dance Studio, you must have all questions answered to the best of your ability. If you are unable to honestly do so, you may not enter the premises at this point in order to ensure everyone's safety in our premises. Please note all forms will be confidential and will not be publicized.

We'll be happy to assist you with any questions, comments, or concerns. Please email us at info@vybedance.com.

Email *

Today's Date (date of this visit) *

YYYY

Full Name *

Reason for Studio Visit *

Are you displaying any possible COVID-19 symptoms including, but not limited to, fever, difficulty breathing, or generally feeling unwell. *

Yes

Other:

Have you travelled out of the country in the past 14 days? *

Yes

To the best of my knowledge, have you been in contact with anyone who has travelled out of the country in the past 14 days? *

Yes

Have you been in contact with anyone who has any symptoms of COVID-19 in the past 14 days *

Yes

Will you continue to maintain cleanliness habits, such as frequent hand washing, minimizing social exposure, and mask wearing in situations where social distancing may be difficult. *

Yes

I consent to a temperature check upon arrival at VYbE Dance with a contactless thermometer *

I consent

I do not consent

I agree that until further notice, I will properly wear a mask to VYbE Dance Company at all times *

I agree

I disagree

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