HEALTH INFORMATION QUESTIONNAIRE (CUSTOMERS AND STUDENTS)
Information supplied in this questionnaire by STAGESCREEN customers provides a record of health and is used in assessing student’s suitability to attend our course. These records will be stored in line with STAGESCREEN GDPR policy for a maximum of 1 year.
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Parent / Guardian Name *
Student Name *
Venue Attended *
Date in Attendance *
MM
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DD
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Are you, or anyone in your household, experiencing any of the following symptoms at present (or have done in the last 14 days)?
Cough *
Shortness of Breath *
High Temperature *
Does the student have any other medical issues this week that we need to be aware of?
Please confirm what tier your home address is currently in
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Have you recently travelled outside the UK? *
If yes, please state which countries.
Please state your date(s) of travel outside of the United Kingdom.
Have you knowingly encountered someone displaying the symptoms of COVID-19 or someone who has tested positive in the last 14 days? *
I, the parent or carer named below, confirm that the above information is accurate to the best of my knowledge and hereby give consent for the information to be shared with STAGESCREEN staff. The student(s) for which I am responsible, and I agree to comply with all hygiene procedures and rules while present on STAGESCREEN sites and understand failure to follow these directives may result in termination of services provided with no refund.
Signed (Parent/Carer name) *
Email *
Mobile Phone number
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