COVID-19 Waiver
ROCKIN TOTS COVID-19 Self-Screening Form
This health screening questionnaire is offered for informational purposes to help you check for COVID-19 symptoms as outlined by the Centers for Disease Control. The guidance you receive depends on the accuracy of the information you provide as well as current guidelines for identifying symptoms associated with COVID-19. Please take the survey and provide the response to Rockin Tots Productions. This is not a substitute for professional medical advice, diagnosis, or treatment of disease or other conditions, including COVID-19. Always consult a medical professional for serious symptoms or emergencies.

Your health and well-being are of the upmost importance and we are taking measures to keep a safe environment for our students and staff. Therefore, anyone coming into the building will be screened and part of our screening process will include taking your temperature and asking the following questions.

Please complete this health screening form once per week before entering the Rockin Tots Studio.  Please complete by class day each week.  

Thank you in advance for partnering with us to promote a safe environment for all members of the Rockin Tots Music Family.

Sign in to Google to save your progress. Learn more
Email *
Clear selection
Parent Full Name *
Child’s full name *
Today’s date *
Temperature checks are required to be completed before entering our facilities.  Do you have a temperature of 100.0 F or higher?   *
In the past 10 days, has your child or anyone in your household tested positive for COVID-19? *
In the past 10 days, has your child experienced fever, a new cough, new loss of taste or smell, or shortness of breath? *
In the past 10 days, has anyone in your household been in close contact with anyone that tested positive for COVID-19? *
If you answered YES to any of these questions please contact us for further instructions before attending classes. rockintotsdarlene@gmail.com or text 917-617-4183 *
By checking this box I am confirming the above information is accurate. *
Required
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
Google Forms